UR Specialist

Summit BHC•Santa Teresa, NM

1d•Onsite

About The Position

The Utilization Assistant provides support to all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information. Works with insurance providers to obtain coverage for patients. Assists in utilization reviews and insurance appeals. Responds to inquiries from patients, their families, and professional referral sources.

Requirements

High School Diploma Required

Nice To Haves

Bachelor’s Degree in social work, behavioral or mental health, or other related health field preferred.
One or more years of direct clinical experience in a psychiatric or mental health setting preferred.

Responsibilities

Assists the admissions department with pre-certifications of care.
Performs pre and post admission benefit verification with managed care organizations.
Reviews medical records of patients for appropriateness of level of care at admission and at intervals determined by documentation in medical record.
Conducts interactive and timely reviews with payers to ensure certification of care.
Maintains accurate documentation and files as it relates to utilization management.
Coordinates information and findings with the business office to help recognize or resolve possible payment problems.
Attends daily treatment team to discuss patient needs and ensure that all disciplines are aware of patient insurance status and needs.
Ensure that insurance benefits are verified in a timely manner.
Communicates any UR or Quality issues as noted in the chart to supervisor immediately to ensure timely resolution of problems.
Responds to telephone and Internet inquires.
Researches insurance company guidelines and uses admission and continuing stay criteria for coverage.