Summary:

Under the general supervision of the Practice Manager of the RIH Partial Hospital Program (PHP) performs insurance reviews for RIH PHP Program to obtain authorization for treatment designated as medically necessary using approved criteria and standards. Determine level of care is consistent with the expectations of third-party payers and/or third party payers� managed care agents. Discuss concerns regarding authorization issues with the primary clinician and treatment team. Serve as consultant/liaison to clinicians involved in the review process. 

Responsibilities:

Under direction and in accordance with established policies procedures guidelines and criteria in the review and assessment of patients' records and clinical data. Review care and treatment received though ongoing communication with treatment providers and review of the medical record.

Communicate with third party payers to obtain authorization for all PHP RIH patients. Obtain authorizations with both primary and secondary insurances as appropriate and deemed to benefit the financial security of the hospital.

The ongoing management of every aspect of the authorization of care and the management of all treatment is done through any of the following mechanisms of communication:

Concurrent review - Level of Care Criteria are utilized to manage the ongoing authorization status of every patient admitted to the hospital at the inpatient partial intensive outpatient and residential level of care within the facility. Assess the medical necessity of continued stay and review with third party payers to assure that the authorization is in place and services are provided in the appropriate setting.

Prospective/Pre-certification Review - Level of Care Criteria are utilized to manage the ongoing authorization status of patients transferring within hospital departments (e.g. transfer from inpatient to partial or partial to inpatient). Assess the medical necessity of continued stay and review with third party payers to assure that the authorization is in place and services are provided in the appropriate setting. At times pre-certify patients to other facilities when required to do so to assist in timely discharge.

Retrospective Review and Appeal Process Management � Continued authorization requests and rigorous tracking of all admitted patients even after discharge to manage authorization of treatment provided through secondary insurance and pending primary insurance where appropriate. Ongoing management of the appeal process where appropriate. Accurate reporting and tracking of all cases involving and appeals/denials/unfunded days.

Maintains all relevant documentation of the initial review concurrent reviews and discharge reviews. If the initial pre-certification indicates a problem with clinical appropriateness funding authorization or program placement the attending physician (or designee) the Patient Registration Department and/or the Director of the Access Center is informed of the problem(s) as appropriate.

Communicate all relevant payer information to the appropriate departments including but not limited to Social Work Access Center Patient Registration and Patient Financial Services.

Assist Patient Financial Services in troubleshooting authorization issues and/or errors as appropriate including communicating with PFS agents and third-party payers to rectify any problems and ensure prompt and full payment of authorized services and encounters.

Communicate unfunded issues as they pertain to authorization of services and meeting level of care criteria. Update the Report and communicate to Administration and relevant parties the barriers to authorization and funding.

Consistently apply the corporate values of respect honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer-friendly geographically accessible and high-value services within the environment of a comprehensive integrated academic health system.

Responsible for knowing and acting in accordance with the principles of the Brown University Health Corporate Compliance Program and Code of Conduct.

Performs other duties as necessary.

Other information:

EDUCATION:

Minimum high school diploma/GED required. Bachelor's degree preferred.

EXPERIENCE:

Minimum of 3-5 years� experience working in clinical inpatient and/or partial hospitalization psychiatric setting required.

Experience in utilization review insurance benefits negotiation and/or case management preferred.

Advanced working knowledge of clinical treatment teams documentation and current practices in child/adolescent psychiatry is beneficial. Requires solid knowledge of psychiatric terminology.

Requires high attention to detail and an ability to understand and explain complicated insurance benefits and level of care criteria to clinical staff and to develop appropriate recommendations for use of existing patient benefits.

Complete understanding of the quality controls that assure records are complete accurate and in accordance with all necessary guidelines.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

Work is performed in a typical office setting.

SUPERVISORY RESPONSIBILITY:

None.

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Brown University Health is a VEVRAA Federal Contractor.

Location: Brown Health Medical Group USA:RI:Providence

Work Type: Part Time

Shift: Shift 1

Union: Non-Union

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