**Weekends are a must: Saturday-Wednesday**
Monthly bonuses- Based on performance
POSITION SUMMARY
The Utilization Review Specialist is responsible for assuring coverage, of clients, by insurance companies (the payers) through completing a pre-certification. The pre-certification or Authorization of coverage is obtained by presenting clinicals of medical necessity based on criteria guidelines.
GENERAL RESPONSIBILTIES
- Authorize, direct and monitor care for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care.
- Communicate directly with insurance companies providing necessary information to obtain authorizations for care.
- Communicate directly with insurance companies providing necessary information for any and all levels of appeal to obtain authorizations for care.
- Update all necessary utilization review notes such as authorization numbers, approved days, call logs, status updates and etc.
- Update and utilize electronic medical records system with utilization review information and notes.
- Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, readmissions, and others as indicated.
- Communicate and obtain appropriate clinical information with physicians and clinical staff for reviews and discharge planning.
- Communicate criteria issues, standards and compliance of criteria needs with clinical team regarding (American Society of Addiction medicine) ASAM standards.
- Participate in quality improvement activities, supporting network development and interfacing with treatment facilities and the professional community on company development (which include but not limited to documentation evaluations and educational training)
- Coordinate with verification team and assure benefits for reviewed clients are met.
- Track benefit usage and advise appropriate parties of exhaustion of benefits.
- Interact with Medical Director or designee to discuss clinical authorization questions and concerns regarding specific cases.
- Perform other tasks and duties as assigned by utilization review department head.
WORKING CONDITIONS AND ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Remote work may be at the discretion of executive and department head members. In determining the allowance of work-from-home and any recurrence, if permitted, is subject to change and be revolted if executive staff may see fit for position. If remotely working the employee is responsible for assuring all appropriate supplies and communication is easily accessible to perform their duties (e.g. internet, printer, scanner, computer, phone, and a HIPAA compliant work space). Work will be tracked by online software, such as Time doctor.
QUALIFICATIONS& EDUCATION
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Nursing Degree (ASN, BSN, MSN) with certification
- Master's Degree in Behavioral Health (MSW, MA, MFT, Psychology, Addiction)
- Fully licensed LCDC or equivalent
- masters or doctorate degree in the behavioral health or nursing/medical field required
- 1+ years’ experience in Utilization Review in Behavioral Health
- Proficient in Microsoft Office and Google documents
- Exceptional communication and organizational skills.
LANGUAGE ABILITY
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
MATH ABILITY
Ability to apply concepts of basic algebra and geometry.
REASONING ABILITY
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk and sit. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.