Utilization Review Specialist - Autism

Nationwide Children's Hospital • Columbus, OH

10d • Hybrid

About The Position

Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care. The position is work from home after a 90-day in-office training period.

Requirements

• Bachelor’s Degree in Social Work, Psychology, or related field, required.
• Three years of behavioral health experience, required.
• One year of experience in pediatric care or services, required.
• Excellent written and verbal communication and interpersonal skills.
• Excellent customer service and organizational skills.
• Working knowledge of CMS and other review agency standards.
• Proficient with software applications including CM, payer web applications, MITS, and others.
• Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel (Occasionally)
• Standing, Walking (Frequently)
• Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing – Far/near, Sitting (Continuously)

Nice To Haves

• Utilization review or utilization management experience, preferred.

Responsibilities

• Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
• Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
• Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
• Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
• Provides education and support regarding utilization review and management activities and processes.
• Analyzes clinical data to identify trends and patterns that may impact patient care.
• Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
• Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level