Utilization Review Resource Specialist Jobs

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BEHAVIORAL HEALTH UTILIZATION REVIEW SPECIALIST

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Intermediate to advanced proficiency in Microsoft applications (Word, Excel and Access), database management, and document preparation

REPORTS TO POSITION: Manager, Utilization Review

Required: 2 years’ experience in similar hospital related position with utilization experience preferred

Strong team working and collaborative skills.

Strong analytical, problem solving and decision making skills.

DATE LAST REVIEWED: March 9, 2023

Determines qualifications for hospital level of care based on set criteria.

Initiates chart reviews, conducts follow-up reviews, and escalates secondary reviews to Physician Advisor as necessary.

Performs other duties as assigned.

Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)

Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)

1 year experience with medical necessity appeals

Implements and organizes downgrades compliantly and per documentation. (10%)

Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)

Communicates with all parties in a professional manner to alert of specific problem issues. (10%)

Traffic record check (as applicable);

Consumer credit check (as applicable);

Reasonable suspicion drug and alcohol test; and

Post-accident or incident drug and alcohol test.

RESIDENCY PREFERENCE AMENDMENT ACT OF 1988

Bachelor’s Degree in Nursing preferred.

Excellent data entry skills and ability to navigate electronic systems applicable to job functions

Ensure all pre-certifications are completed for inpatient and outpatient services

Work with facilities to ensure documentation requirements are met

Interface with managed care organizations, external reviews, and other payers

2 or more years experience billing UR healthcare industry – in the mental health/addiction field.

Working knowledge of clinical case formulation for substance abuse/mental health treatment.

Notify supervisor when pre-certification is denied.

Develop collaborate relationships with third party payers and managed care companies

Continue education with new information regarding criteria for various insurance companies.

Track how particular Managed Care Companies approve residential days in keeping with progress notes under our ASAM criteria.

Average to above average computer skills.

Above average verbal and writing skills.

Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)

Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)

1 year experience with medical necessity appeals

Implements and organizes downgrades compliantly and per documentation. (10%)

Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)

Communicates with all parties in a professional manner to alert of specific problem issues. (10%)

Coordinate utilization management reviews for all assigned inpatient, partial hospitalization and intensive outpatient program patients.

Coordinates closely with Director of Utilization Management, Nursing and Clinical Services.

Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies.

Obtains authorizations for services, coordinates peer-to-peer reviews for assigned caseload.

Understands medical necessity criteria and facilitates accurate and timely documentation to support advocacy of services.

Master’s Degree in Social Work, Marriage and Family Therapy or Counseling from an accredited school or BSN, RN

Function as a member of the Billing Team to ensure that all daily responsibilities are met.

Aid in verification of benefits when needed.

Excellent verbal and written communication skills.

Prior Utilization Review experience in a Substance abuse environment.

Knowledge of ASAM and medical necessity guidelines as it relates to substance abuse.

The Utilization Review Specialist will perform pre-certification reviews, concurrent reviews and discharge reviews for substance abuse facilities.

MUST HAVE EXPERIENCE WITH EATING DISORDER CLIENTS*

Complete precertification process and associated documentation.

Manages time effectively, setting priorities, and consistently meeting deadlines.

Excellent verbal and written communication skills.

Maintain efficient methods for ensuring the medical necessity and appropriateness of prescribed level of care.

Oversee the entire UR process for client journey from admission to discharge.

Manage authorization denials including referral for peer review.

Assist the treatment team in understanding payer requirements for admission, continued stay and discharge planning.

3-5 years of related ABA, Substance Abuse, and/or Mental Health experience.

Superior written and oral communication skills

Solid understanding of insurance benefits and coverages.

Strong computer skills (Word, Excel, billing software).

Prepare critical staffing analysis materials for regular Partner and management meetings

Actively assess and analyze attorney workloads, experience, interests, feedback, and availability to effectively staff them on matters

Maintain up-to-date knowledge of firm legal products and how they overlap with attorney expertise to ensure nuanced staffing on cases

Effectively communicate case needs and manage attorney expectations regarding their workload

Collaborate with system managers (3E, Handshake) to identify opportunities for efficiencies in LS&U operations

Possess strong analytical skills with exceptional attention to details and accuracy

Annual Salary is $34,500.00 plus generous benefits package!

Generous state paid benefit allowance to help cover insurance premiums

Training opportunities for CEU requirements

A wide choice of health insurance plans with no pre-existing condition exclusions or limitations

Flexible spending accounts for health care expenses or dependent care

Employee assistance programs and health and fitness programs

Strong project management skills, with a demonstrable ability to corral and manage details in a fast-paced, fluid environment

Knowledge of all confidentially requirements regarding patients and strict maintenance of proper confidentiality on all such information.

Collaborates at a high level to problem solve on complex cases with Manager

Follows up on all outstanding authorizations and reports all barriers to Manager

Collaborates with Revenue Team and Admissions to improve patient experience from the front door through discharge

Partners with Manager and Director to troubleshoot workflows and processes to achieve efficiency gains in current and future company systems

Knowledge of UR processes required for all payor sources i.e. precertification, concurrent reviews, discharge review.

Complete initial precertification for all levels of care.

Collaborate with clinicians/case managers to obtain pertinent clinical and discharge information.

Liaison between insurance and clinical staff, providing information to clinicians/case managers regarding dispositions that would be approved by insurance.

Consult with Admissions Department regarding specific LOC issues, insurance requests, and/or criteria questions.

Conduct concurrent reviews on assigned cases.

Req 3 years Case management experience in an acute care hospital setting

Assists with denial management to identify opportunities to improve department processes

Demonstrates collaborative working relationships with case managers and payers to ensure authorizations are obtained and current.

Maintains awareness of payer/reimbursement practices and requirements.

Req 3 years Clinical experience.

Req 1 year Experience utilizing InterQual Criteria in CERME format.

Experience with PHP/IOP and SUD.

Experience working with commercial health plans.

Experience w admission and concurrent reviews.

Perform all other duties as assigned Skills:

5 years of Utilization Review.

Ability to create a sense of urgency.

Maintains knowledge of Payer requirements for peer to peer process, Skilled nursing facility authorization, & LTAC reviews.

Provides provider and care team ongoing education regarding utilization review/management.

Verifies authorization of services and communicates information to case management/nursing team.

Makes decisions based on evidence based practice, research, and UR nurse higher order critical thinking skills and experience.

Maintains knowledge of Payer requirements regarding length of stay for observation and transition to Inpatient

Documents actions taken and outcome(s) in Cerner Case Management tool, payer information.