Utilization Review Specialist
About The Position
A Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. This role involves analyzing patient records to determine the legitimacy of admission, treatment, and length of stay. The specialist interfaces with managed care organizations, external reviewers, and other payers, advocating on behalf of patients with substance abuse, dual diagnosis, psychiatric, or emotional disorders to managed care providers for necessary treatment. The UR Specialist also contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient’s stay and assists the treatment team in understanding the insurance company’s requirements for continued stay and discharge planning.
Requirements
- Bachelor’s degree required.
Nice To Haves
- Master’s degree preferred.
- Previous utilization review experience in a psychiatric healthcare facility preferred.
- Current unencumbered clinical license strongly preferred.
- CPR certification and Crisis Prevention Training (CPI) preferred.
Responsibilities
- Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services
- Completes pre and re-certifications for inpatient and outpatient services.
- Reports appropriate denial, and authorization information to designated resource.
- Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
- Participate in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
- Works with DON to ensure documentation requirements are met.
- Ensure appeals are completed thoroughly and on a timely basis.
- Interface with managed care organizations, external reviews, and other payers.
- Communicate with physicians to schedule peer to peer reviews.
- Accurately report denials.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
