Behavioral Healthcare Utilization Review Spec

Horizon Behavioral Heal•Lynchburg, VA

9d•$46,349 - $74,158•Onsite

About The Position

The Behavioral Healthcare Utilization Review Specialist works on-site and will proactively monitor utilization of services for clients, reviewing for quality of services and medical necessity. The employee will review clients’ medical records to ensure appropriate utilization of treatment resources, medical necessity, proper documentation, and compliance with federal and state regulations, and certification requirements of insurance plans or other managed care organizations (MCOs). This position will report to the CQI Manager.

Requirements

Bachelor's degree from an accredited college/university in an applicable human services field.
Two years of continuous quality improvement and/or utilization review experience.
Proficiency in MS Office software and EMR systems.
Ability to collaborate with all members of clinical team/medical providers.
Excellent verbal and written communication skills.
Ability to work independently as well as with a team.
Excellent organizational and time management skills.
Willing and available to work modified schedules (weekends, holiday, etc.) as required.
Ability to drive and must possess a valid driver's license.
Knowledge of behavioral healthcare terminology, the course and progress of substance abuse treatment and medical terminology.
Knowledge of Medicaid and MCO regulations and policies, relevant to behavioral healthcare and substance use.
Knowledge of Utilization Review protocols and auditing skills.
Knowledge of DSM 5, CPT Codes and ICD 10.
Knowledge of levels of care and medical necessity.
Ability to review and understand medical records, treatment plans and progress notes.
Ability to extract and analyze data.
Ability to develop and present statistical and narrative reports.

Nice To Haves

Master’s degree in social work, Mental Health Counseling, or related health field preferred.
At least one year of managed care experience.
Behavioral Health experience is desirable.
May be required to travel to different Horizon worksites during the day based on operational needs or provide admin support at other locations.
Regular attendance at trainings and Horizon meetings may require travel to a variety of Horizon sites.

Responsibilities

Proactively monitor utilization of services for clients.
Review for quality of services and medical necessity.
Review clients’ medical records to ensure appropriate utilization of treatment resources, medical necessity, proper documentation, and compliance with federal and state regulations, and certification requirements of insurance plans or other managed care organizations (MCOs).