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Utilization Review Specialist

United States·University Heightsmid

Healthcare Non-ClinicalUtilization Review Specialist

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Quick Summary

Key Responsibilities

Complete initial, concurrent, and retrospective reviews of patient care in a timely manner to ensure continuous coverage for patients in inpatient treatment. Initiate, schedule,

Requirements Summary

Experience: 1-2 years related experience required. 3-5 years related experience preferred. 1-2 years-experience in behavioral health utilization review preferred.

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Healthcare Non-ClinicalUtilization Review Specialist

What We Offer

~1 min read

The Utilization Review (UR) Specialist will independently facilitate clinical reviews, as necessary, on admission and for continued stay care. The UR Specialist will review the medical record to ensure medical necessity of admission as well as ongoing inpatient and outpatient treatment. The UR Specialist will determine the avenues for advocacy on behalf of patients with insurance for utilization of insurance benefits throughout the patient’s treatment. The UR Specialist will also respond to intake inquiries via phone, fax and email.

Responsibilities

~1 min read

→Complete initial, concurrent, and retrospective reviews of patient care in a timely manner to ensure continuous coverage for patients in inpatient treatment.
→Initiate, schedule, and meaningfully participate in peer reviews and expedited appeals between third-party payers and facilities as needed.
→Maintain sophisticated and current knowledge of mental health disorders including DSM-V knowledge, ICD-10 diagnoses and treatment processes.
→Utilize clinical information and knowledge of medical necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners including the admitting psychiatrist.
→Collaborate with treatment team to discuss clinical authorization and quality of care.
→Consistent and timely response to emails and other communications relating to utilization review.
→Prepare and submit appeals utilizing their independent knowledge and expertise.
→Familiarity with processing correspondence with adherence to HIPPA guidelines.
→Assist with the Intake process for Bluestone admissions, including answering phone calls and reviewing faxed or emailed referrals.
→Complete all data tracking as needed.
→As relevant to scope of practice, complete psychosocial assessments or group treatment services for either inpatient or outpatient admissions.

Requirements

~1 min read

Experience: 1-2 years related experience required. 3-5 years related experience preferred. 1-2 years-experience in behavioral health utilization review preferred.
Education: Associates Degree in Nursing, Social Work, Mental Health/Behavioral Sciences required. Bachelor’s or Master’s Degree in related field preferred.
Licensure: LPN, RN, LSW, LPC, MFT, LISW, LPCC or LMFT required.
Skills: Sensitivity in relating to persons of varying backgrounds and demonstrated ability to work with diverse groups of people possessing various strengths, aptitudes and abilities.
- Ability to perform job responsibilities with a high degree of initiative and independent judgment.
- Demonstrated oral and written communication skills and effective interpersonal skills.
- Proficiency in using Agency computer systems and software as required to perform essential job functions. Practical and creative problem solving skills.