Utilization Reviewer

Recruitment #101316-MDCZ07-350600

Summary Statement

The incumbent is responsible for reviewing and analyzing all inpatient client stays within the Delaware Psychiatric Center.  Work includes: reviewing admissions and continue stay data to determine the appropriate use of clinical resources while assisting with eliminating barriers to client discharge.  The incumbent will gather data and produce reports to validate admissions, continued stays, internal and external client transfers and client discharges from the facility.  The incumbent will be the hospital interface with third party payers in order to assure documentation for medical necessity and continued stay.

Essential Functions

Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, incumbents can complete job duties of similar kind not specifically listed here.

  • Examines patient charts to analyze the appropriateness and clinical necessity of admissions, continued stays and support services.
     
  • Conducts reviews of patient charts for completeness of documentation in support of active psychiatric care or general psychiatric care.
     
  • Prepares reports of chart deficiency findings and submits to treatment units for correction.  Follows up to ensure corrections are made.
     
  • Conducts chart reviews to ensure compliance with Federal, State and licensing agency standards and third party payer regulations.
     
  • Communicates with responsible department heads, unit directors, utilization review physician advisors and the committee to ensure the identification of inappropriate allocations of hospital resources and initiates corrective actions.
     
  • Initiates denial and reinstatement letters to notify patients, family and third party payers that level of care has been changed affecting payment process.
     
  • Maintains records of charts reviewed and deficiencies identified.

Job Requirements

JOB REQUIREMENTS for Utilization Reviewer
Applicants must have education, training and/or experience demonstrating competence in each of the following areas:

  1. Three years experience in health or human services work such as applying theories, principles, laws and practices of health or human services programs and services that assist with and improve life for individuals, families, or communities in the areas such as financial support, employment, unemployment, housing, health care, disease prevention, substance abuse, child protective services, physical/mental health treatment and prevention, rehabilitation.
  2. Six months experience in analyzing and evaluating professional services for direct patient care such as medical or clinical services, social services, psychology, physical therapy, occupational therapy, or nursing services.
  3. Six months experience in interpreting laws, rules, regulations, standards, policies, and procedures.
  4. Six months experience in using an automated information system to enter, update, modify, delete, retrieve/inquire and report on data.
  5. Six months experience in narrative report writing.
  6. Knowledge of alcohol, drug and mental health treatment programs.
  7. Knowledge of developing policies or procedures.

Conditions of Hire

Pre-employment Drug Testing:  Upon a conditional offer, you must undergo pre-employment drug testing as part of the hiring process.  

Criminal background check:  A satisfactory criminal background check is required as a condition of hire.  The recruiting agency may require the applicant to pay for the criminal background check as part of the conditional offer of hire.

Benefits

To learn more about the comprehensive benefit package please visit our website at http://ben.omb.delaware.gov/

Selection Process

The application and supplemental questionnaire are evaluated based upon a rating of your education, training and experience as they relate to the job requirements of the position.  It is essential that you provide complete and accurate information on your application and the supplemental questionnaire to include dates of employment, job title and job duties.  For education and training, list name of educational provider, training course titles and summary of course content.   Narrative information supplied in response to the questions must be supported by the information supplied on the application including your employment, education and training history as it relates to the job requirements.

Once you have submitted your application on-line, all future correspondence related to your application will be sent via email.  Please keep your contact information current.  You may also view all correspondence sent to you by the State of Delaware in the “My Applications” tab at www.delawarestatejobs.com.

Accommodations

Accommodations are available for applicants with disabilities in all phases of the application and employment process.  To request an auxiliary aid or service please call (302) 739-5458. TDD users should call the Delaware Relay Service Number 1-800-232-5460 for assistance.  The State of Delaware – An Equal Opportunity and Affirmative Action Employer.