Director of Utilization Review

at  Catholic Charities Diocese of Trenton

JOB SUMMARY: Responsible for overseeing the coordination of the service area’s MCO process for identified programs. Includes precertification and continued stay reviews, as well as ensure all insurance denials, appeals and reconsiderations are completed in a timely manner Responsible for ensuring that MCO’s, Progress Notes, and necessary documentation are completed on time. That programs meet State and Federal Licensing documentation requirements so that CCDoT can bill for services provided. Collects information required to authorize services, assess necessity and appropriateness of treatment.

• Attend MCO stakeholder meetings
• Audit Charts, Progress Notes/ IRP’s/treatment plans to ensure they meet standards and deadlines.
• Review Suspense reports, problem solve suspense/billing issues, use Microsoft BI
• Verify consumer insurance through the eMevs system.
• Assist with IME processes to verify status of IRP’s. Record & track status of all IRP’s.
• Complete daily reports and assign cases to the Utilization Coordinators, as well as coordinate with other departments as needed to complete the Utilization Review process
• Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for level of care. Develop forms to track status of projects.
• Work with Program Directors on gathering necessary data to complete and submit quarterly QCMR reports to DMHAS
• Collaborate with Access Center, Billing, and Program Director’s/Supervisors regarding MCO/Insurance needs.
• Communicate, in written & verbal form, assessments & observations of consumers to other treatment team members.
• Collaborate with Directors as needed for compliance and quality measures.
• Provides EHR/RCM training to staff as well as demonstrates solid competencies with navigating Cerner system. Demonstrate solid competencies with entering data into contractor systems.
• Identify and provide additional training needs in consultation with Nurse Executive for all IBHS programs.
• Assist Compliance in ensuring staff remain in compliance with agency and state regulations.
• Other duties as assigned by IBHS and Agency Leadership.
  KNOWLEDGE/SKILLS/ABILITIES: Knowledge NJ MCOs. Ability to multi-task and handle various responsibilities/duties/issues simultaneously while meeting timelines. Detail and problem solving oriented, possess strong organizational skills, excellent interpersonal, written and verbal communication skills, the ability to establish positive interpersonal relationships with staff and colleagues, as well as external community for networking and partnership building.
  SUPERVISORY REQUIREMENTS: Yes