JOB SUMMARY: Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals, Standard Appeals, External Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare letters for member and provider appeals that did not meet criteria. Gather, analyze, and report information regarding member and provider appeals. Maintain files and logs for all appeals. Follow all appeals and retrospective reviews through resolutions. Remain current on applicable UM trends and regulations and review current policies and procedures for compliance. Work closely with the Business Office to ensure proof of authorization and denials communicated accurately in Midas. Interface with various managed care organizations and other payers to resolve issues related to appeals. Maintains all records/data pertaining to the Utilization Management Program. Actively participates in Utilization Management/Medical Records Committee meetings including presentation of reports, statistics, etc. Participates in the hospital-wide Quality Assurance Program.

JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each primary duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.

Education: Bachelor's Degree in behavioral health related field required; Master Degree preferred.

Experience: 1 year experience in Utilization Management and 1 year experience in mental health/psychiatry preferred.

Knowledge: Possesses knowledge of utilization review, insurance and managed care procedures. Current knowledge of regulating /accrediting agency guidelines. Basic knowledge of computer skills and statistical analysis desired. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Effective oral and written communication skills to support patient advocacy/negotiating skills to ensure quality reviews with payers.