Utilization Review Specialist - Outpatient -Riverside Healthcare - Kankakee - IL

Riverside Medical Center is seeking a passionate, creative and goal-oriented UR Specialist to join the team at the behavioral health unit located in Kankakee, IL. We specialize in compassionate behavioral health services, including crisis stabilization for acute mental health and substance use disorders. Our philosophy is built on a psychosocial model of care and follows the core principles of resilience, recovery and restoration.

The Behavioral Health Utilization Review Specialist collaborates with physicians and other staff members to provide accurate documentation necessary in conducting pre-admission and admissions reviews. These reviews will be completed concurrently to determine the appropriateness of hospital level of care. The Behavioral Health UR Specialist will determine the appropriateness for inpatient level of care based on documented severity of illness and intensity of services.

• Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
• Collaborate with other clinical team members in reviewing actual and proposed psychiatric care and services against review criteria.
• Collaborates with Case Management Services in facilitating referrals to other facilities.
• Collaborates with physicians to influence appropriate utilization of resources and transitions from one level to another.
• Collaborates with revenue cycle in appeals of payer denials.
• Conducts admission and concurrent reviews on assigned patients.
• Demonstrates understanding of psychotropic medications.
• Demonstrates understanding of safety measures required for patient care (ie precautions, milieu rules, etc.)
• Educates members of the patient's healthcare team on the appropriate access to, and use of various levels of care.
• Encourage healthcare team members in collaborative problem solving activity regarding appropriate use of resources.
• Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers.
• Identify potentially unnecessary services and care delivery settings and recommend alternatives, if appropriate.
• Keeps current on all regulatory changes that affect delivery of reimbursement of acute care services.
• Maintain appropriate documentation on each patient in ACA notes.
• Participates in daily report and patient care staffings to maintain knowledge about intensity of services and the progression of care.
• Promote documentation that accurately reflects intensity of services, quality and safety indicators and patient's need to continuing stay.
• Recognizes and responds appropriately to risk factors.
• Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
• Works efficiently and completes work in established time frames.

• Bachelor's degree peferred
• Ultilization Management preferred
• Behavioral Healthcare knowledge or experience is essential
• Must be able to demonstrate the ability to work independently and effectively as a healthcare team member and prioritize work.
• Must have interpersonal and communication skills.

Licensure or Certification requirements:

• None