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The Utilization Review Specialist is responsible for monitoring adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services. Monitors the appropriateness of hospital admissions and extended hospitals stays. Completing data collection of demographic, claim and medical information; non-medical analysis; and outcomes reporting.

Who Are We:

Westborough Behavioral Healthcare Hospital (WBHH) provides psychiatric stabilization and dual diagnosis treatments for Children, Adolescents and Adult populations in both inpatient and outpatient settings. Our goal is to ensure patients and their loved ones feel comfortable and are well informed regarding treatment options.

We are conveniently located in Westborough near the intersection of Route 495 and Route 9. The hospital operates 24/7 with multiple shifts available.

Essential Duties:

• Initiates authorization requests are complete or requests additional data as necessary.
• Performs concurrent reviews for patients to advocate for authorization for services needed.
• Advises treatment team in documentation of medical necessity in the medical record.
• Maintains communication with the Social Services department to facilitate timely discharge planning.
• Enters complete and accurate documentation into the system describing all patient related admitting/registration activities.
• Follows all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.
• Submits discharge clinical as required by payers.
• Upholds the Organization's ethics and customer service standards.

Requirements

3 years of experience in psychiatric setting preferred. Knowledge of health care service delivery systems, and third party reimbursement; knowledge of managed care environment.

Ability to apply and interpret admission and continued stay criteria; understanding of admission and discharge function; familiarity with medical terminology, diagnostic terms and treatment modalities; knowledge of medical record keeping.

Clinical degree such as Social Work, Psychology, Health Information Management or other related healthcare field is preferred or related experience.