Utilization Review Coordinator

Function:The Utilization Review Coordinator (URC) has the primary responsibility of monitoring adherence to the agency’s utilization review procedures and ensuring appropriate leveling of client needs to determine the level of care needed, admission, length of stay, and discharge planning.Organizational duties & responsibilities:

1. The primary responsibility of all staff is to ensure the safety and well-being of all Ramey-Estep/Re-group (RE) clients.
2. Supports the mission, vision, and values of RE.  Facilitates and adheres to the agency’s code of ethics, policies, and procedures.
3. Supports all functions that attain and maintain accreditation and compliance with regulatory agencies.
4. Supports and facilitates positive interaction with clients and staff by exhibiting both in-office and in-public when carrying out job duties:  individual maturity, respect for others, a team-centered approach, maintenance of confidential information, and awareness and sensitivity to cultural and other differences in clients and staff.
5. Exhibits effective communication skills, including proper use of agency communication systems.
6. Participates in appropriate professional development programs to attain and maintain competency.
7. Effectively manages financial and physical resources to achieve the mission of RE.
8. Reports incidents of abuse or potential abuse involving clients to the appropriate authorities and RE.

Essential Duties and Responsibilities:

1. Maintains up-to-date training and knowledge of the ASAM Criteria, which are used in determining appropriate levels of care (LOC) for clients.
2. Conducts or reviews initial screening of clients to determine appropriateness for admission to the Residential Recovery Programs.
3. Submits and/or monitors the initial authorization process to ensure timely and thorough submission of the authorization request.
4. Monitors fax, email, and phone calls to ensure authorization determinations are received and that all information is provided to the insurance.
5. Enters authorization information into the electronic health record, Credible promptly to ensure client services can be billed appropriately and efficiently.
6. Completes concurrent reviews for clients to ensure extended stays are medically necessary and are also documented in the client record. The URC will either review or conduct ongoing assessments to ensure all required information is collected and available for each concurrent review.
7. Complete ongoing training with RRR clinicians to ensure a thorough understanding of ASAM Criteria dimensions and documentation requirements to justify LOC.
8. Completes Daily Billing Vouchers for all clients in RRR programs (LOC 3.5, LOC 3.1, and UNITE).
9. Collects and reports data related to the length of stay for clients to assist in analyzing trends and identifying needs. The URC will work collaboratively with the supervisor and RE Leadership to problem-solve identified issues.
10. Works collaboratively with the case manager and medical staff to make appropriate referrals for those clients that do not or no longer meet medical necessity for the residential LOC.
11. Maintains open communication with the entire treatment team, including supervisor, therapists, case managers, peer supports, medical staff, medication management provider, step-down service supervisors, etc., regarding LOC determinations so that appropriate LOC services are being provided and timely discharge planning is taking place.
12. Assists in conducting and documenting thorough diagnostic assessments to determine the level of care and medical necessity and provides recommendations within the appropriate time frame when needed.
13. Provides length of stay and LOC information to the treatment team to assist with the planning, writing, and timely updates of the client’s care plan.
14. In the absence of the assigned therapist, may step in to assist with the completion of group or individual therapy to ensure clients are receiving required daily services.
15. The URC documents all provided services in accordance with agency policy and within the required time frames.
16. Promotes a positive view of RE and Re-group to the public and outside agencies.
17. Attends program-specific treatment team meetings for all clients, as appropriate, for clients in the Residential Recovery Program.
18. Maintains current licensure and stays within ethical guidelines provided by your licensure board.
19. Participates in supervision and consultation regularly.
20. Collaborates effectively with other Re-group services and community partners.
21. Ability to be flexible and adapt to changes in schedules and work environment.
22. Provides consistent, quality treatment to all clients.
23. Ensures all necessary records are maintained and kept confidential.
24. Ensures entries in all treatment plans and narrative reports to MCOs are done in a professional, concise manner and will be submitted as needed to maintain a current authorization for services.  
25. Participates in an “on-call” schedule when appropriate.

1. Performs other duties as assigned.

Working conditions/environment:

1. Shift is generally Monday – Friday, but hours will vary based on the client’s needs.
2. Holidays, weekends, and extra hours may be required.
3. Meals are provided for staff when on campus.
4. Intense, unpredictable population with the possibility of verbal and physical aggression.
5. Fast-paced environment with the need for quick decisions to deal with any crisis that may arise.
6. Primary work setting is in the office but also can take place in the community, including the client’s home, especially for on-call work.
7. Maintains a positive, professional attitude contributing to a supportive work environment.

minimum job requirements:Education:Master’s degree from an accredited university in a clinical field, i.e., social work, counseling, psychology.
Licensed or license-eligible required.Experience:Previous experience in substance use treatment programs is preferred.Specific Skills andrequirements:Must be at least 21 years of age.
Must have strong leadership and organizational skills.
Must have excellent communication and conflict-resolution skills.
Technical requirements include proficiency with Microsoft Word, Excel, PowerPoint, and any other applications used by the organization or regulatory agencies.
Must maintain a valid Driver’s License and insurability.
Ability to understand and relate to the needs of clients from diverse backgrounds.
Ability to read, write and converse in English.
Successful completion of a pre-employment drug screen.
Successful completion of a background screening.
Successful completion of a TB skin test or proof of a negative chest x-ray or other documentation.Specialized Licenses or training:Maintains 40 hours of Annual Training through Relias or other appropriate sources.
Maintains at least minimum training for licensure.
Maintains at least 20 hours per year of substance abuse-related training per AODE regulations.
Attends all assigned training specific to job assignment.Physical Requirements:The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee is regularly required to stand, walk, talk, hear, and smell.  The employee frequently is required to sit; use hands to finger, handle, or feel; reach with hands and arms; and stoop, kneel, crouch, and climb stairs.  The employee is occasionally required to climb, balance or run.  The employee must frequently lift and/or move up to 50 pounds or more.  Specific vision abilities required by this job include close vision, distance vision, and peripheral vision.  Supervisory REquirements:N/A

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