Case Review Analyst

ICBD • Lauderdale Lakes, FL

18h • Onsite

About The Position

As a Case Review Analyst, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources.
The Case Review Analyst will assist in reviewing and processing records to submit for authorization to the payors. This position collaborates closely with clinical teams, insurance providers, and other healthcare professionals to support efficient and effective patient care.

Requirements

• Associate's or Bachelor’s degree in Healthcare Administration, Medical Records, Behavioral Health, or a related field.
• Minimum of 1 year of experience working with clinical records, medical documentation, or utilization review, preferably in ABA therapy, behavioral health, or healthcare settings.
• Proven experience in utilization reviews or a related field with a strong understanding of healthcare service delivery and documentation processes is highly desirable.
• Must maintain clean background/drug screenings and driving record.
• Familiarity with industry standards, guidelines, and best practices related to utilization review.
• Ability to analyze complex clinical documentation, treatment plans, and medical records.
• Strong critical thinking skills to assess the appropriateness and necessity of healthcare services.
• Strong analytical and critical thinking skills.
• Excellent communication and interpersonal skills.

Nice To Haves

• Certification in Health Information Management (e.g., RHIA, RHIT) is a plus but not required.

Responsibilities

• Review and analyze clinical records, including received documentation from payors, to ensure compliance with ABA therapy best practices and insurance requirements.
• Accurately input and maintain clinical records, authorization requests, and related documents into the electronic health records (EHR) or other relevant systems.
• Assist in tracking and organizing all documentation for utilization reviews, ensuring that all records are complete, accurate, and accessible for audits and reviews.
• Monitor the status of pending authorizations and document updates or changes to treatment plans in a timely manner.
• Assist in processing and reviewing requests for treatment authorization, working with clinicians to verify that all necessary documentation is available for review.
• Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies.
• Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews.
• Assist in preparing records and documentation for external audits or insurance company reviews, ensuring that all necessary information is submitted and compliant with guidelines.
• Identify any discrepancies, missing documentation, or areas where clinical records may require updates to meet the standards.
• Assist in coordinating with insurance providers to obtain authorization and resolve any issues related to service utilization or claims denials.
• Provide requested documentation and supporting materials for authorization and reauthorization requests, ensuring timely submission to insurance companies.
• Maintain records of communications with insurance companies, clinical teams, and other relevant stakeholders.
• Analyze trends in authorization requests, approvals, and denials and provide reports or insights to management to identify areas for process improvement.
• Track utilization patterns, service delivery, and compliance with payer requirements to support continuous improvement in the utilization review process.
• Communicate effectively with team members to ensure the smooth processing of treatment authorizations and timely updates on status or concerns.
• Provide clear communication regarding the status of clinical record reviews, authorization requests, and insurance queries.
• Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery.

Benefits

• 21 paid days off (15 days of PTO, which increases with tenure, plus 6 holidays).
• Flexible Spending Account (FSA) and Health Savings Account (HSA) options.
• Medical, dental, vision, long-term disability, and life insurance.
• Generous 401(k) with up to 6% employer match.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree
• Number of Employees: 1-10 employees