• Bachelor of Science in Psychology or 5 years of Clinical Psychology or Psychiatry experience.
• 3 years of experience in acute care mental health and substance abuse rehabilitation.
• 3 years of experience in discharge planning, utilization management, case management, performance improvement, managed care reimbursement, or transition of care, care coordination, home health.
• Level II finger printing background and Good Moral Character Affidavit.

• Completes and documents all phases of utilization review and avoidable day reporting. Negotiates reimbursement with payors and/or other arrangements, and access to necessary care.
• Assists in developing and coordinating the implementation of Discharge Plan A and alternative Plan B including documentation.
• Assesses, interprets, and communicates the overall multidisciplinary plan of care to the insurance carrier.
• Coordinates and facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target length of stay.
• Attends and collaborates in weekly multidisciplinary meetings, and co-leads Care Coordination Rounds per policy, and refers patients for Complex Care Rounds.
• Works together with clinical team in gathering necessary information required by insurance carriers.
• Reviews clinical medical record using clinical decision support to determine denial/appeal of inpatients' authorization.
• Serves as a liaison between the insurance carrier medical team, and Nicklaus Children's Health System medical team to authorize additional days of stay.
• Determines appropriateness of admission within established timeframes, and as per health plan guidelines, continued stay based on the severity of illness and prescribed treatment plan by the treating psychiatrist/s.
• Determines potential to actual outliers, and follows through with MD.
• Performs admission, continued stay, & retrospective utilization review to determine appropriateness. Serves as the Psychiatry CM representative in interdepartmental committee programs/teams/studies.
• Recommends and carries out performance improvement activity as necessary to ensure optimal performance of the department.

• Maintains accountability by ensuring compliance thru timely completion of licensures, certifications, all competencies, health requirements (PPD, N95, Flu, etc.), and education requirements.
• Maintains accountability and timekeeping expectations as outlined by MCHS Timekeeping and Attendance policy and procedures. Ensures behavior is compliant with communication standards.
• Ensures behavior meets and/or exceeds targeted service scores as measured by the Service Index and/or the inter-departmental service survey.

• Current and valid license to practice as a Registered Nurse in the state of Florida preferred.
• Certification in CPHQ, CMS, ACM, or CCM preferred.
• Basic level proficiency in Microsoft Word, Excel, and Outlook.
• Able and available to work a flexible/rotating schedule including holidays and weekends.
• Demonstrates commitment to the Partners-in-Caring process and the behavioral expectations in all interactions and in performing all job duties.
• Performs duties in a manner which promotes quality patient care.
• Highly desirable to have experience in discharge planning, clinical pathways and continuous quality improvement.
• Able to communicate effectively both verbally and in writing in a clear, concise, and courteous manner.
• Fluent in Spanish preferred.
• Possesses effective negotiation skills.
• Working experience with electronic medical records, and/or discharge planning and case management systems.
• Able to interpret, adapt, and react calmly under stressful conditions in a pleasant manner.
• Able to relate cooperatively and constructively with customers and co-workers.
• Able to maintain confidentiality of sensitive information.
• Able to establish necessary professional relationships, and interact effectively with internal and external customers.
• Able to work in a fast paced environment, and effectively manage and use resources to successfully meet the competing deadlines of a variety of tasks, problems, and projects.
• Able to use logical and analytical thinking to interpret technical data, and solve a broad range of problems.
• Able to work independently when interacting with organization's clinical and non-clinical customers and outside vendors/payors.

(EOE DFW)

11/28/17