UTILIZATION REVIEWER

GENERAL SUMMARY The Utilization Reviewer collects, analyzes and documents information from medical records and providers to be used by the Utilization Manager in prospective reviews, authorizations or in making initial adverse determinations. Also to supports the Utilization Manager by conducting utilization reviews and granting authorization decisions individuals already receiving services from the (Local Mental Health Authority) LMHA. Ensures requests are complete, accurate, and clearly falls within the DSHS UM Guidelines. ESSENTIAL DUTIES & RESPONSIBILITIES Essential functions are the basic job duties that an employee must be able to perform, with or without reasonable accommodation. The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. The omission of a function does not preclude management from assigning essential duties not listed herein if such duties relate to the position.

• Collects, analyzes, and documents information from medical records and providers that is used by the Utilization Manager to in their decision-making processes.
• Conducts retrospective reviews and review of data to detect outliers.
• Conducts utilization reviews and grants authorization decisions for continued stays, including overrides and add-on services for individuals who are already receiving authorized services from the LMHA.
• Does not conduct prior authorizations for LOCs or hospitalizations.
• May Assist the Utilization Care Manager if the Utilization Reviewer staff possesses the required credentials.
• Monitors patients charts and records to evaluate if care is concurrent with patients treatments.
• Reviews requests for authorization that do not clearly meet guidelines and refers to Utilization Manager for approval.
• Performs other related duties as required.

MINIMUM ENTRANCE QUALIFICATIONS Education and Experience

• Bachelors degree
• At least three (3) years clinically appropriate experience in the treatment of individuals with mental illness and chemical dependency.

Licenses or Certifications

• QMHP-CS. Minimum qualifications as defined in the current DSHS Mental Health Community Services Standards.

Other Requirements

• Must maintain a valid drivers license and automobile insurance coverage, be able to travel as needed, and be able to meet on a consistent basis the driving record requirements of the Companys auto insurance carrier if you drive your vehicle during company business.
• Must maintain required credentials and mandatory training requirements to ensure compliance with all State regulations and CHCS policies.

PREFERRED QUALIFICATIONS

• Prior work experience in a Utilization Management department
• Bilingual English and Spanish

SUPERVISION

• Job has no responsibility for the direction or supervision of others.

COMPETENCIES FOR SUCCESSFUL PERFORMANCE OF JOB DUTIES Knowledge of:

• Mental health diagnoses and outpatient treatments for individuals with severe mental illness.
• UM Guidelines and services offered per level of care.
• Electronic Medical Records.
• Medical terminology.
• Modern office procedures, methods and computer equipment.
• Microsoft office products including Word, Excel, PowerPoint and similar computer software.

Skilled in:

• Gathering, organizing and presenting data for analysis.
• Customer service.
• Organization and time management.
• Performing a variety of duties, often changing from one task to another of a different nature.
• Performing basic mathematical functions such as addition, subtraction, multiplication, division, percentages, and ratios.

Ability to:

• Accurately organize and maintain paper documents and electronic files.
• Complete and submit required documentation.
• Effectively communicate, both verbally and in writing.
• Ensure compliance with all State regulations and CHCS policies.
• Establish and maintain effective working relationships.
• Maintain accurate and complete records.
• Maintain the confidentiality of information and professional boundaries.
• Meet schedules and deadlines of the work.
• Understand and carry out oral and written directions

PHYSICAL DEMANDS The physical demands 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 the essential functions.

• Must have adequate mobility that requires frequent walking, standing, bending, stooping, kneeling, reaching (vertical and horizontal), using fingers, hands, feet, legs and torso in various care.

Monday - Friday 8:30am - 5:30pm 6800 Park Ten - East

Code : 7023-1

SALARY RANGE: $55,893.90-$83,831.70