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Title

Utilization Management Clinician (LMSW or RN) 

Location Greater Grand Rapids, Michigan Area  
Full-Time/Part-Time Part-Time  
Shift Days  
Description

Position Summary:

The Utilization Management Clinician manages all aspects of the certification for payment process. Completes admission authorization, out of network transfers, initiates concurrent authorization, completes retrospective authorizations and minimizes financial risk by maintaining timely communication with all payers. The Utilization Management Clinician must demonstrate excellent customer service and have enthusiasm about the program and the Pine Rest organization.

Principal Duties and Responsibilities:

  • Organize and prioritize workload by contacting payers/authorizing agencies in a timely fashion in an effort to get hospital services approved.
  • Maintain a professional and collaborative relationship with the multi-disciplinary team to obtain information regarding severity of patients’ symptoms and intensity of services required for their care and to facilitate appropriate resource utilization in the provision of safe patient care.
  • Attests to and represents the clinical presentation of patients accurately according to the patient record while advocating for patients’ treatment needs with authorizing agencies and payers.
  • Obtaining pre-certification for admission and conducting concurrent reviews with third party payers.
  • Conducts reviews of Medicare admissions to assure stay meets criteria.
  • Remains current on all third party payer requirements for authorization of services and the appeals processes.
  • Works with the Pine Rest Contact Center to assure a smooth flow of admissions and maintains a good working relationship with the nursing units and physicians.
  • Anticipate patient's length of stay, treatment plans and outcomes based upon clinical knowledge, experience and length of stay guidelines.
  • Participate in discharge rounds/patient care conferences as indicated.
  • Responsible to role model the mission and values of the organization, presenting a professional image that is projected in appearance, attitudes and behaviors, time management and communication skills. Provides spiritual, emotional, social, mental and physical support to patients.
  • Commitment to demonstrating Relationship Based Case in Hospital Based Services.
  • Must maintain annual training and demonstrate competency in the required programmatic training.
  • Performs other duties or functions as assigned.
 
Position Requirements

Required/Desired Qualifications:

Education, Training, and Experience:

  • Must be an RN or LMSW and possess or be eligible for a license in the State of Michigan.
  • Strong background in the provision of psychiatric services required, as well as excellent written and verbal communication skills.
  • Knowledge of medical terminology required.

Specific skills, knowledge, and abilities:

  • Ability to provide care/service within the scope of: Holding a conviction to express Christ’s love and compassion to recipients of services, coworkers, and surrounding communities through integrity, stewardship, empowerment, the promotion of diversity, and professional excellence.
  • Ability to provide cultural competent care with a wide range of individuals in a diverse community setting.
  • Ability to establish and form solid relationships with both internal and external customers is necessary.
  • Important to be able to apply Medical Necessity and Intensity of Services criteria.
  • Good computer skills (including use of Microsoft Office Suite, use of electronic medical records, etc) needed.
  • Has knowledge of the Michigan Mental Health Code, The Joint Commission and Centers for Medicaid and Medicare standards preferred.
  • Requires physical and emotional stamina to deal with physical, emotional, social, cultural and spiritual needs of patients.
  • Ability to work in a potentially adverse environment.
 
About the Organization Pine Rest is a nonprofit, free standing, behavioral health system founded in 1910 in Grand Rapids, Michigan. This comprehensive behavioral health center, coupled with the Pine Rest network of 18 outpatient clinics and satellite offices in Michigan and Iowa, provide individualized and group therapy for people of all ages and all levels of need. Pine Rest clinicians offer therapeutic services in behavioral health for people of all ages and all levels of need across the continuum of care within a Christian framework.





Pine Rest has a 198-bed inpatient hospital program with a 36-bed child and adolescent inpatient and a large partial hospital program for adolescents. Additionally, Pine Rest has many inpatient services for adults, including: four 22-bed adult inpatient units each designed for a different level of acuity, a 22-bed co-occurring substance use disorder adult inpatient unit, a large adult partial hospital program, and a 26-bed older adult inpatient unit.





The Pine Rest Community and Residential Services Division also provides a wide array of services. With over 220 residential beds across a variety of programs, including treatment for substance use disorders, homes for adults with intellectual and developmental disorders, adults with mental illness, and a program for youth aged 11-18 with extensive trauma histories focusing on trauma treatment and life skills programming.





The Pine Rest Behavioral Health Solutions Division partners with behavioral health and medical organizations to increase access to psychiatry services and to provide a continuum of behavioral health and telepsychiatry services throughout many communities across the State of Michigan.


 
Number of Openings 2  
EOE Statement Pine Rest Christian Mental Health Services an equal employment opportunity employer and complies with the following:

RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN
Executive Order 11246, as amended, prohibits employment discrimination based on race, color, religion, sex, sexual orientation, gender identity, or national origin, and requires affirmative action to ensure equality of opportunity in all aspects of employment.

PAY SECRECY
Executive Order 11246, as amended, protects applicants and employees from discrimination based on inquiring about, disclosing, or discussing their compensation or the compensation of other applicants or employees.

INDIVIDUALS WITH DISABILITIES
Section 503 of the Rehabilitation Act of 1973, as amended, protects qualified individuals with disabilities
from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. Disability discrimination includes not making reasonable accommodation to the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, barring undue hardship to the employer. Section 503 also requires that Federal contractors take affirmative action to employ and advance in employment qualified individuals with disabilities at all levels of employment, including the executive level.

PROTECTED VETERANS
The Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212, prohibits
employment discrimination against, and requires affirmative action to recruit, employ, and advance in
employment, disabled veterans, recently separated veterans (i.e., within three years of discharge or release from active duty), active duty wartime or campaign badge veterans, or Armed Forces service medal veterans.
 
Department None Specified 


This position is currently not accepting applications.

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