Covenant Health

Utilization Review Coordinator, Quality Management

Full Time, 80 Hours Per Pay Period, Day Shift

Peninsula Overview:

Peninsula, a division of Parkwest Medical Center, has set a new standard for effective, innovative and caring mental health services in East Tennessee. With a combined total of more than 75 years of experience, Peninsula has helped thousands of people recover from disorders and dependencies, and lead healthy, positive and productive lives.

Offering both inpatient and outpatient services for children, adolescents and adults, Peninsula is a leader in the changing healthcare environment. The hospital is located in Blount County, with outpatient centers in Knox, Blount, Loudon and Sevier Counties. Additionally, Peninsula offers care specifically designed for seniors with co-existing psychiatric and medical conditions at the Senior Behavioral Center located at Parkwest Medical Center. Peninsula is truly committed to improving the health of the people and communities it serves.

Position Summary:

Reviews information with payors to obtain authorization for payments. 

Recruiter: Sandra Simmons  || ssimmon6@covhlth.com || 865-374-5368

• Review admission information to assure appropriateness of admission to inpatient services and assigns initial number of days / sessions per third party payor requirements.
• Works collaboratively with the treatment team and accesses consultation and involvement whenever appropriate
• Prior to end of approved number of authorized days, reviews clinical justification for continued stay and assigns further days, if justification meets criteria.
• Informs providers of cases in which justification has not been established for initiation of process if provider chooses to appeal decision.
• Collects data related to U.M. activities and prepares ongoing statistical reports.
• Performs other necessary reviews / studies in the areas where possible problems have been identified and reports findings to the appropriate staff / committees.
• Works with Peninsula Hospital to identify and address problems related to the utilization process and to monitor and track the resolution of these problems.
• Performs Quality Improvement functions.
• Reviews clinical information / request for initial and continued treatment and authorizes sessions per guidelines.
• Works collaboratively with Medical Director and accesses consultation and involvement whenever appropriate in accordance with the U.M. plan.
• Collects data related to U.M. activities and prepares reports as required.
• Performs reviews / studies in areas when possible problems have been identified and reports findings to the appropriate committee(s).
• Performs Quality Improvement functions within the Peninsula Behavioral Health system.
• Attends workshops, seminars, and in-services to heighten knowledge and skills related to job performance.
• Educates as needed related to protocol / standards of the U.M. process.
• Participates in effective resolution of customer concerns.
• Participates in the development and evaluation of program policies and criteria within Peninsula Behavioral Health.
• Assists in the formulation of health service utilization and cost forecasts with ongoing responsibility to monitor and execute controls designed to meet budgeted targets.
• Provides medical/psychiatric leadership/consultation to Provider Relations, Medical Utilization Management, and Quality Management Staff in decision making.  Ensures that corrective actions plans which result from these decisions are implemented.
• Monitors compliance with state and federal regularly requirements which apply to behavioral health.
• Provides ongoing feedback and recommendations to the Manager on staffing structure, policies and procedures, as they are related to manage care.
• Provides daily appropriate direction to all departments on issues pertaining to prior authorization, concurrent and retrospective review.
• Confers with participating physicians who have questionable patterns of utilizing inpatient or ancillary services, referrals, and/or emergency room visits which are identified from ongoing review or retrospective utilization data.
• Monitors current utilization review criteria and length of stay norms.
• Assists with education of physicians on updated utilization review guidelines.
• Participates in Utilization Management Committee.
• Performs other related duties as required.

Minimum Education: 

RN License or Licensed Therapist from an accredited program

Minimum Experience: 

At least five (5) years experience in mental health field, two (2) years experience of utilization management and knowledge of third party requirements. Must be able to prioritize/execute multiple complex tasks and have exceptional oral and written communication skills.  Previous successful experience in managed care management is desired.

Licensure Requirement: 

Current RN or Therapy license.