Description:
We are seeking a highly skilled and detail-oriented Utilization Review Specialist to join our team. This individual will be responsible for reviewing patient admissions and clinical information to ensure medical necessity and compliance with utilization review guidelines. The role involves managing authorization processes, advocating for patients, and collaborating with clinical staff and insurance companies to facilitate the utilization review process.
Key Responsibilities:
- Review patient admission and clinical information to ensure medical necessity and compliance with state-specific utilization review guidelines.
- Obtain initial and continuing authorization for treatment services.
- Use electronic medical records systems (e.g., Kipu EMR, Alleva)to manage patient data, billing information, and claims processing.
- Manage authorization denials, including referrals for peer reviews.
- Advocate on behalf of patients to ensure the maximum length of stay at the appropriate level of care.
- Interact with insurance companies in a respectful and professional manner, adhering to policies and procedures.
- Document and record all necessary information related to patient care and authorization processes.
- Monitor and track new and ongoing authorization cases.
- Collaborate with clinical staff to ensure that necessary information is obtained and timely reviews are performed.
- Assist the treatment team in understanding payer requirements for admission, continued stay, and discharge planning.
- Participate in team meetings and case conference reviews.Maintain confidentiality of patient information in compliance with HIPAA regulations.
- Perform other related duties as necessary to meet the organization’s ongoing needs
Requirements:
- 3-5 years of experience in Substance Abuse and/or Mental Health.
- Understanding of mental and behavioral health treatment services.
- Understanding of insurance benefits and coverages.
- Excellent attention to detail to ensure all necessary information is captured and properly documented.
- Ability to work independently and within a team environment. Ability to multi-task, prioritize, and meet expected deadlines.
- Strong computer skills, including proficiency with Word, Excel, and billing software.
- Superior written and oral communication skills.