DIR - Utilization Review / Mgmt

Responsibilities La Amistad Behavioral Health Services is a leader in the field of behavioral health care, and our experts are committed to providing the highest quality of care in an atmosphere that nurtures healing and growth. La Amistad enjoys full accreditation by The Joint Commission. La Amistad believes in building healthy communities, which start with healthy individuals, linked through sound relationships to their families, friends, neighbors and peers.

Director of Utilization Review: Directs and coordinates the utilization review process. Supervises Utilization Review staff. Assures optimum quality of patient care in the most cost-effective manner.

Assists in performing admission and continued-stay reviews. Works with the Physicians and the Social Services department to ensure quality of documentation of patient care. Identifies Utilization Review problems.

Coordinates and maintains data for use of leadership team. Program Planning and Treatment Direct the response to request for services, including the initial response, the assessment and referral process, the designation of appropriate level of care, initiating of services, and follow up activity. Review the effectiveness of the comprehensive interface with external reviewers, communicate with external reviewers and managed care organizations to assure timely and appropriate interactions, monitor outcomes of reviews and provide consultation as needed.

Review the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness. Assure patients are receiving effective and appropriate treatment, based on the level of care. Establish standards for customer relations and monitor the interactions between Utilization Review staff and customers to evaluate the effectiveness of customer service.

Direct the program services offered, consulting with facility management in the planning, development, implementation and evaluation of the utilization review program. Maintain current awareness of mental health activities in the community Maintain an awareness of community and market-related activities which includes knowledge of the activities of other providers, needs of local payers and the political climate related to mental health Participate in clinical team analysis and evaluation of current services offered at the facility Strategically solve problems that encompass the larger view of the organization, and establish goals by utilizing an understanding of organizational dynamics in planning and problem solving.

Remain current on all clinical techniques, and provide direction to staff and facility personnel. Participate in developing, justifying and controlling the annual budget for department personnel, facilities and equipment. Ensure strategic program goals and objectives are consistent with overall facility goals and objectives.

Develop goals and objectives, policies and procedures related to the operational needs of the programs scenarios. Consult with facility management in the development and facilitation of program activities which assure an optimal therapeutic experience for all patients Participate with ensuring that individual patients and their families are involved in the development of individualized treatment plans.. Maintain an active involvement and awareness of all patient admissions, discharges and transfers.

Meet regularly with program managers and the Medical Director and program staff to ensure compliance with program goals and objectives. Serve on Facility Committees and attend meetings as assigned. Provide services to current referral sources to assure their satisfaction and continued associations.

Develop and maintain a system to minimize and address denials in consult with the facility Business Office Manager and CFO. Personnel Management and Staffing Maintain and allocate a well qualified core of staff resources. Assure that hiring, disciplinary actions and termination procedures are conducted in accordance with hospital policies.

Involve appropriate facility management in all decisions, and review these decisions with COO prior to implementation. Assure adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate. Assure adequate orientation for new employees of the Utilization Review Department.

Provide for educational needs and professional development of staff. Ensure that the staff schedule and configuration will meet the needs and demands of the patient population and census and adjust it accordingly. Ensure an adequate system of communication and reporting is maintained between all staff members, as well as other departments involved in the ongoing operation of the program.

Create a structure that best meets the needs of the organization, particularly department organization related to supervision and assignment of staff. Routinely review job assignments and utilization of staff. Clinical Leadership Conduct department meetings on a regular basis.

Work with clinical leadership to ensure interdisciplinary treatment planning is organized with participation of all appropriate clinical disciplines. Ensure all patient, family and referral complaints are promptly handled. Coordinate the collection of outcome data within the company deadline.

Continuous Quality Improvement Ensure that a system is developed to provide continuity of care and communication with family and appropriate referral sources, and ensure the system is evaluated and reviewed regularly. Daily reporting of denials to CFO. Ensure the department meets Joint Commission, Medicare and federal and state regulatory requirements.

Develop and implement a Performance Improvement tracking system, evaluate the results quarterly, and report results to the Performance Improvement Committee in a timely manner. Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem solving actions. Review all department risk management occurrence and ensure that complete and timely reports are submitted to Risk Management.

Analyze statistical data of the program to determine and respond to trends. Additional Standards Implement planning and teaching staff documentation training. Serves on Facility Committees as assigned.

Accepts responsibility for professional growth and development. Demonstrates a professional attitude and supports the objectives of the Facility philosophy through internal and external communications and interactions with all levels of staff, patients, family members, guests, community, and referral sources. Adhere to facility, department, corporate, personnel and standard policies and procedures.

Attend all mandatory facility in-services and staff development activities as scheduled. Adhere to facility standards concerning conduct, dress, attendance and punctuality. Support facility-wide quality/performance improvement goals and objectives.

Maintain confidentiality of facility employees and patient information Note: The essential job functions of this position are not limited to the duties listed above. Qualifications

1.

Bachelor’s degree in psychology or related field, or RN licensure from an accredited school and at least two years experience in the mental health field. 2.

Three (3) to five (5) years’ experience in chart analysis and utilization review in the psychiatric and chemical dependency field preferred. 3. License/Certification: N/A 4.

Good oral and written communication skills required to communicate in a clear and concise manner with patients, physicians, staff and administration. Stable emotional makeup required to work in a fast paced environment with frequent interruptions. 5. Physical

Work is sedentary requiring sitting most of the day. Sitting at least six (6) hours a day while processing paperwork, answering the phones and other described duties. One half of the day is