Summary
The Sub-Acute Rehab Utilization Review Manager ensures high-quality, financially sound care delivery by overseeing regulatory compliance in billing, coding, and documentation. In collaboration with the Administrator, Therapy Manager, and MDS Coordinator, this role manages utilization review processes from preadmission through discharge, including prior authorizations, recertifications, and peer-to-peer reviews with third-party payors. The Manager works closely with the interdisciplinary team to support accurate documentation, evidence-based practice, and optimal transitions of care. Responsibilities also include tracking PDPM reimbursement accuracy, supporting external audits, resolving data integrity issues, and staying current with regulatory and accreditation changes. Additionally, the role contributes to staff education, equipment audits, and continuous quality improvement initiatives aligned with Medicare and other payor requirements.
Essential Job Responsibilities
- Provide patient care, treatment, and services within the scope of licensure, certification, or registration, in accordance with applicable laws, regulations, and organizational needs
- Communication and collaboration: Coordinating and communicating with insurance companies, providers, and patients to facilitate authorization and reimbursement processes and ensure smooth transitions of care.
- Compliance and quality assurance: Staying current with regulations, guidelines, and technologies in healthcare utilization management, ensuring compliance and enhancing operational efficiency and the quality of care provided.
- Scrutinize vendors and charges, process invoices to ensure appropriateness of charges
- Stay current with regulatory and accreditation changes impacting the rehabilitation industry
- Assist the interdisciplinary team (IDT) with discharge planning and entering in admission information
- Audit rehabilitation equipment regularly and recommend replacement as needed
- In collaboration with the SAR Therapy Manager, review clinical documentation and practices, and serve as a champion for implementing evidence-based practices
- Serve as a clinical resource for compliance, coding and billing related to Medicare and CMS documentation requirements in the sub-acute/SNF setting
- Coordinate with IDT members and the MFB continuum to identify optimal transitions of care and document recommendations appropriately
- Manage utilization review functions for sub-acute rehabilitation at preadmission, admission, continued stay and discharge stages
- Coordinate prior authorization and recertification communications (calls or faxes) with various third-party insurers as a part of the reimbursement process
- Develop and maintain strong relationships with key payers to enhance access to inpatient services at Mary Free Bed
- Determine patient review dates based on established diagnostic criteria
- Coordinate physician peer-to-peer reviews and appeals with third-party insurers
- Track managed care-authorized PDPM reimbursement against MDS determined PDPM reimbursement; request reassessment of case mix groupers from managed care partners as appropriate to advocate for optimal reimbursement
- Assist with chart preparation and data analysis for external audits as requested
- Collaborate with various departments to resolve data integrity issues, pre-certification problems, coding discrepancies, and documentation concerns
- Perform other duties as assigned by Sub-Acute Rehabilitation Administrator
- We’ll embrace all people by:
- T reating everyone with dignity and respect.
- O pening more doors to opportunity for others to succeed.
- G rowing talent and people.
- E nsuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual orientation or socioeconomic status.
- T aking action against discrimination.
- H onoring our differences and how we collaborate.
- E ducating staff, patients and the communities we care for.
- Restoring hope and freedom, together
Customer Service Responsibilities
Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.
Responsibilities in Quality Improvement
Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.
Essential Job Qualifications
- Bachelor’s degree in clinical therapy or related discipline
- Minimum of 1 year of experience in Utilization Management or related clinical field such as nursing or therapy
- Minimum 4 years work experience in a relevant clinical rehabilitation setting.
- Knowledge of billing procedures and systems
- Specialized training or hands-on experience in quality improvement and related therapy areas, including MDS, PDPM management, Medicare billing, coding, and documentation concepts in the SNF setting.
- Strong organizational skills with ability to manage multiple priorities effectively
- Proficient in information management, with the ability to communicate, interpret, and present data clearly in both written and verbal formats
- Proven ability to work independently as well as collaboratively within multidisciplinary team to solve problems and drive results
- Demonstrates a proactive, adaptable approach with a strong sense of urgency and a collaborative team mindset
- Capable of multitasking and delegating responsibilities to ensure timely completion of projects
- Committed to the organization’s mission, with a results-driven attitude and a willingness to go above and beyond to achieve goals
Preferred Job Qualifications
- 2+ years’ experience in Utilization Management
Physical Requirements for Essential Job Qualification
Levels :
- None (No specific requirements)
- Occasionally (Less than 1/3)
- Frequently (1/3 to 2/3)
- Majority (More than 2/3)
Remain in a stationary position: Majority
Traverse or move around work location: None
Use keyboard: Frequently
Operate or use department specific equipment: None
Ascend/Descend equipment or ladder: None
Position self to accomplish the Essential Functions of the role: None
Receive and communicate information and ideas for understanding: Frequently
Transport, position, and/or exert force:
Up to 10 pounds: Occasionally
Up to 25 pounds: _____
Up to 50 pounds: _____
Up to 75 pounds: _____
More than 100 pounds: _____
Other weight: Up to 35 pounds Occasionally
Other: None
Consistent with the Americans with Disabilities Act (ADA), it is the policy of Mary Free Bed Rehabilitation Hospital to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Talent Acquisition team at [email protected] .
Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.
