Behavioral Health, Clinical Validation, Communication Skills, Cross-Functional, Documentation, Hospital, Legal Standards, Nursing, Organizational Skills, Patient Care, Patient Care Authorizations, Psychiatry and Mental Health, Psychology, Registered Nurse (RN), Regulatory Compliance, Social Work, Team Player, Utilization Management
This role involves coordinating patient care to promote positive outcomes and optimal reimbursement through clinical reviews, documentation, appeals, and reporting.
Qualifications include a Bachelor's Degree in Nursing, Psychology, or Social Work (Master's preferred), CA RN license, and 3-5 years of experience in inpatient psychiatric or utilization management settings.
Key responsibilities:
- Conduct daily clinical reviews for various payers to secure treatment authorization.
- Collaborate with multidisciplinary teams to ensure appropriate care and payer compliance.
- Complete appeals and support post-claim reviews, audits, and compliance activities.
- Work with hospital departments to align documentation with patient conditions.
- Contribute to utilization data reporting and facilitate physician reviews as needed.
- Must demonstrate effective communication, knowledge of behavioral health care, and understanding of hospital operations. The position emphasizes service excellence, professionalism, teamwork, and compliance with legal standards.
A
Alan B. Miller Medical Center