Under general supervision, the UR Specialist reviews medical records of patients who are under treatment for substance use disorders to ensure proper utilization of treatment resources. Reviews patient records for proper case documentation, and medical necessity of treatment in relation to federal, state and county regulations and assesses continuing treatment plans. Ultimately formally advocates for required patient treatment with medical providers.
Duties and Responsibilities include but are not limited to:
Review patient admission data and clinical documentation to ensure compliance with county and state regulations relating to medical necessity and case documentation;
When appropriate, interviews clients, significant others, and consult with existing clinical team;
Consults with medical and treatment staff regarding patient diagnosis, medical justification, length of treatment, and case documentation;
Assesses records for the appropriate level of care and treatment, aftercare, and discharge planning for patients;
Represents the clinical team and administration in disagreements as to care plans with medical staff/managed care representatives;
Advocates for required patient treatment with managed care providers;
Provides training and information about utilization requirements to clinical, supervisory, and management staff;
Participate with departmental staff in utilization and quality improvement meetings and projects;
Prepare memorandum, letters, correspondence and comprehensive daily patient status summaries;
Participate in audits and comprehensive clinical reviews to ensure agency compliance on utilization review regulations.
Works in conjunction with the Psychiatric Nurse Practitioner to ensure quality patient care and assessments;
Works with technicians to ensure basic duties are performed, ie, vitals, critical to patient care and utilization review needs;
Provides support to the clinical staff as needed;
Provides didactic and psychoeducational groups on medication management and other topics as assigned;
Reviews medication-assisted therapies and recommends as needed for continuity of care;
Works closely with the administrative team to enhance program objectives and goals;
Recommends principles and methods of counseling and the accepted techniques for assessing psycho-social behavior in cases where UR reviews are pending;
Works independently with community resources providing continuity of care referrals;
Applies and consistently reinforces the client’s rights and responsibilities while in the care of the organization;
Performs other duties as required.
Bachelors and Master’s degree or a professional degree in Nursing and a current license. Understanding of psychological and social aspects and characteristics of substance use disorders and mental illness.
Should have a working knowledge of substance use disorders and diagnosis as well as co-morbid conditions affecting individuals in post-acute withdrawal. Valid driver’s license preferred.
Communicates effectively in oral and written format.
Maintains effective interpersonal relationships.
Understand and applies state, federal and local regulations and compliance standards and interprets laws governing quality assurance and utilization review.
Analyze treatment plans, which include the diagnosis of client behavioral and emotional problems.
Use good judgment in order to make critical decisions about the medical necessity of treatment.
Work efficiently in intervention mode, and is able to maintain composure during peaks in client census;
Working understanding of Electronic Medical Records (KIPU)