JOB SUMMARY:

Provides admission, continued stay and discharge reviews on all patients assigned, assures adequacy of patient records related to utilization review. Under general supervision, provides professional assessment, planning, coordination, implementation and reporting of complex clinical data and supports the operations of Rimrock’s programs and placement of patients in programs. Assures adherence to state statutes and rules, CARF standards, and federal regulations including HIPAA and 42 CFR Part 2. Positively represents the organization and promotes Rimrock’s Mission to the community.

ESSENTIAL FUNCTIONS:

UTILIZATION REVIEW RESPONSIBILITIES:

1. Responsible for assuring timely admission and continued stay reviews on admitted patients.
2. Ensures referral to appropriate and cost-effective healthcare services to patients.
3. Assures professional staff documentation of patient appropriateness for continued stay.
4. Assembles and assures that records are prepared and documents patient treatment episode in case of denials in order to appeal if required.
5. Works directly with Patient Financial Coordinator to keep her informed of all utilization review activity.
6. Attends morning staffing and Patient Care Monitoring meetings to be informed of patient needs and progress for utilization review.
7. Provides insurance verifications and authorizations when scheduled.
8. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review.
9. Receives and processes requests for appeal of denials, responds to complaints per UR guidelines, maintains utilization review and appeal logs.
10. Analyzes all patient records, and participates in interdisciplinary collaboration with all professional staff.
11. Abstracts data from records, maintains and reports statistics.

Required Skills Required Experience

CERTIFICATE OR LICENSE: Licensed Addiction Counselor with three years experience in addiction counseling and current LAC license in Montana.  Behavioral Science degree preferred.

• Bachelors Degree in education required. Masters Degree preferred.
• Minimum of 4-6 years experience working with DoD/VA/community providers, patients and families with issues pertaining to TBI education and training required.
• Experience in the care of patients with TBI – in-patient, out-patient, or rehabilitation settings is required.
• DVBIC/DCoE background in TBI preferred.
• Certified Brain Injury Specialists (CBIS) certification is preferred
• Must have knowledge of community education and outreach techniques and basic TBI clinical and policy issues.
• Must have excellent communication skills, including writing skills. Must be able to speak in public.
• Interpersonal skills a must.
• Understanding of DoD and VA clinical networks to identify access points for training and education required.
• Must be able to mentor subordinates.
• Ability to manage conflict, build rapport, and navigate complex situations leading to a positive outcome required.
• Must adhere to legal, professional and ethical codes with respect to confidentiality and privacy.
• Must be a US Citizen
• Must be available to travel locally, regionally and nationally.

 DLH CORPORATION IS AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, PREGNANCY, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN, AGE, PROTECTED VETERAN STATUS, OR DISABILITY STATUS.