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Nurse Manager, Utilization Review and Clinical Documentation (LVN license req.) - Houston, TX

(LVN license required) Cenikor Foundation is a non-profit organization and one of the largest substance abuse treatment centers in the nation. We are currently seeking a Nurse Manager, Utilization Review and Clinical Documentation in our corporate office located in Houston, TX.

JOB SUMMARY:

The Nurse Manager, Utilization Review and Clinical Documentation is responsible for clinical expertise, insurance knowledge, familiarity with third party payor medical necessity requirements, and effective communication skills to analyze client accounts, medical records, and invoices to assist in approval of services and resolution of authorization denials to meet client access needs. The Nurse Manager, Utilization Review and Clinical Documentation will provide direct oversight for Utilization Review Specialists, as well as perform quality reviews of clinical documentation and provide education as needed.

ESSENTIAL FUNCTIONS:

  1. Responsible for daily behavioral health clinical care coordination, and will oversee utilization management, support and care management activities for the foundation’s clients.
  2. Facilitate utilization review activities for all levels of behavioral health care and substance abuse, including detoxification, residential, partial hospitalization, intensive outpatient and outpatient-related to authorization requests.
  3. Coordinate efforts between payer contacts, case managers, nurses and contacts within Cenikor facilities as needed to accomplish this task.  This includes utilization review activities, care management activities (which may include on-site reviews) and significant coordination with other departments within Cenikor Foundation, facilities and counselors to promote effective, efficient clinical care.
  4. Provide direct oversight for Utilization Review Specialists, perform quality reviews of clinical documentation and identify training opportunities and deficiencies.
  5. Prepare and facilitate training as needed based on opportunities identified during quality review process.
  6. Complete or contribute to the completion of various outcome reporting, including monthly activity and success tracking and input to long-range strategic plans.
  7. Maintain appropriate documentation via electronic databases.
  8. Report regularly to the leadership on clinical denial activities, including managing success rate and outcome data and continually provides fact-based information on clinical denial performance with recommendations on process improvements to avoid denials in the future.
  9. Meet routinely or on an as needed basis with payers as appeals progress through various levels of review, working with payer clinical resources to resolve cases.
  10. Coordinate appeal process and maintain appropriate follow-up on appealed claims and contact information.  This will include contact with third party payers, insurance medical directors, case management, and utilization review staff to request reconsideration and/or appeal of claims requiring clinical intervention. Contact may be by phone, fax, written, and/or in person.
  11. Responsible for ensuring effective coordination and collaboration between the Access Center and Insurance Departments with other departments within the foundation.
  12. Maintain strict confidentiality on all client and foundation matters and refer questionable issues to your supervisor.
  13. Work collaboratively with Executive Leadership on continuous improvement of revenue cycle processes.
  14. Uphold the core principles of Cenikor’s culture and create a positive working environment for all team members.
  15. Perform additional duties as assigned and consistent with the exempt functions as defined in this job description.

QUALIFICATIONS FOR THE POSITION:

Skills, Knowledge and Abilities:

  • Knowledgeable of Utilization Review Processes and requirements
  • Knowledgeable of current national healthcare policies and trends
  • Knowledgeable of payer medical necessity requirements, reimbursement methodologies and contracting
  • Knowledge of leadership, management, and quality improvement concepts
  • Skilled in effective verbal and written communication to a variety of audiences through a range of modalities.
  • Knowledge of Microsoft Office software required, including specific MS Outlook calendar experience.
  • Ability to consistently uphold the Core Principles of Cenikor’s Culture:
    • Demonstrate mission of service to our clients
    • Positive, respectful communication with both staff and clients
    • Demonstrate self-motivation and perseverance to achieve goals
    • Role model appropriate, professional behaviors including appropriate client boundaries
    • Work effectively as part of a team, helping to set up others for success

Education:

  • Graduation from an accredited school of nursing. (LVN, or RN) required
  • Bachelor of Science in Nursing (BSN) preferred.
  • Interqual and/or Milliman training

Experience:

  • Minimum LVN licensure with two to three years providing direct clinical care for clients in facility-based and/or outpatient psychiatric or chemical dependency treatment facility.
  • The ideal candidate will have an RN, current license to practice nursing, three to five years’ experience in behavioral health/clinical nursing, and two years of experience in utilization review with a third party payer or commercial healthcare payer.

IMPORTANT NOTES:

DRUG FREE WORKPLACE

EQUAL OPPORTUNITY EMPLOYER

 

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