Utilization Review Coordinator

Pyramid Healthcare is dedicated to offering the highest quality of care to those we serve.

A focus on client-focused care establishes our family of brands as respected leaders in addiction treatment, mental health recovery and eating disorder treatment modalities.

Pyramid Healthcare offers comprehensive behavioral healthcare defined by supportive environments that offer patients the strength they need to overcome life’s challenges.

We offer behavioral healthcare services – psychiatry, addiction recovery, mental disorder treatment, etc. – that allow clients at all stages of recovery or rehabilitation to reclaim health and well-being.

Deliverables/Principal Results Expected:  Perform admission, continued stay and discharge reviews on all managed care clients.  Maintain positive relationships with referral sources and insurance companies.  Track admissions, continued stay and discharge ASAM requirements for county referrals.  Maintain organized system of reporting to counselors when ASAM’s are due and when review calls are to be made.  Maintain current insurance eligibility information through EVS, Navinet, etc.  Monitor Census for accuracy of funding.  Attend clinical staffing to obtain information for client reviews.  Maintain daily UR database accurately.  Perform Act 106 reviews and follow up appeals.  Track all county referrals for documentation of admission calls.  Maintain and participate in chart reviews to ensure proper paperwork is in place.  Work directly with Billing Department to reduce uncovered days of funding. Investigate cases with insurance and referral sources to recuperate lost days of funding.  Report to the Assessment Manager on a weekly basis.  Manage all self-pay clients and clients with copays, deductibles, coinsurance and liabilities.  Reduce client balances.  Other duties as assigned.

Technical Competencies: Provide the company with accurate information to ensure full financial coverage for each client day.

Provide the referral source(s) with timely information to ensure good customer focus.

Maintain client confidentiality and provide a safe therapeutic treatment.

Knowledge of local, state and federal regulations.

Knowledge of facility contracts and agreements.

Knowledge of medical terminology, appeal and denial process, composition of medical records.

Knowledge of data entry (primarily Excel) and mathematics.

Knowledge of pre-certification process and ASAM.

Knowledge of CARF standards, release of information and confidentiality.