Utilization Review Specialist

Clean Recovery Centers•Lake Magdalene, FL

1d•$45,000 - $60,000•Onsite

About The Position

The Utilization Review Specialist (URS) is responsible for managing the revenue flow for each client at Clean Recovery Centers by liaising with insurance companies. This role involves establishing client files, maintaining insurance authorizations from pre-certification through continuing stay reviews until discharge, and ensuring appropriate reimbursement for the level of care provided. The URS utilizes strong communication, reading, and writing skills to achieve this. The ideal candidate will be adept at gathering information from clinicians, navigating Electronic Medical Records (EMRs), and preparing cases for presentation. This role also includes maintaining internal tracking documents and spreadsheets, reviewing medical necessity and documentation, and communicating health concerns to obtain necessary information. The URS will call insurance companies for pre-certification or concurrent reviews, attend team meetings to share information and train clinicians on data needs, and build positive relationships with insurance providers. Additionally, the URS will identify reimbursement trends, report them to supervisors with supporting graphics, promptly address denials by obtaining additional medical history, and communicate treatment plans for ongoing authorization. Ensuring prompt communication to management regarding denials or payor issues is crucial. The role requires close collaboration with all departments, accurate record-keeping of all insurance transactions and communications, and timely transfer of information to the billing department. Proficiency in insurance company portals (Payspan, Zelis, etc.), Microsoft Office Suite (Word, Outlook, Excel), and Adobe is required. The URS must report to work as assigned, maintain a professional workplace, and exhibit acceptable overall attendance. Attendance at in-service and educational training is necessary. Employees are required to report personal symptoms of suspected illnesses and contagious diseases to their supervisor, report incidents, accidents, and occurrences per policy, and maintain the safety of the physical environment. The role demands independent problem-solving and follow-through, along with performing other assigned duties.

Requirements

High School Diploma or equivalent
Experience with ASAM and LOCUS criteria
Ability to interpret ASAM, LOCUS InterQual, 12 step and Treatment Planning for SUD and MH and to apply information to patient authorizations
Ability to work with a team and have effective communication, organizational and interpersonal skills
Ability to work under stressful conditions and be flexible in relation to department needs
Understanding of medical and behavioral health terminology
Knowledge of state and federal statutes regarding patient confidentiality
Attention to detail
Knowledge of Insurance company portals, payspan, zelis and other portals
Knowledge of Microsoft Word, Outlook and Excel required
Knowledge of Adobe required

Nice To Haves

Experience preferred in behavioral health initial and concurrent review processes

Responsibilities

Create and manage the flow of revenue for each client through liaison with insurance companies.
Establish client files with insurance information and maintain authorization for reimbursement from pre-certification through continuing stay reviews, through discharge.
Use communication, reading, and writing skills to establish the most appropriate reimbursement for the level of care being provided.
Gather information from clinicians, navigate EMRs, and create cases for presentation.
Maintain internal tracking documents and spreadsheets daily and/or as instructed.
Ensure the necessity and appropriateness of care, effective benefit management, and coordination.
Review medical necessities and medical record documentation and communicate health concerns for obtaining information.
Call insurance companies to obtain precertification or concurrent with the level of care.
Attend team meetings to gain information and provide training to clinicians as to data needs.
Establish positive relationships with insurance providers.
Identify trends in reimbursements and report to supervisor through verbal and generation of graphics.
Promptly work on denials of level of care and obtaining necessary additional medical history to overturn denials.
Follow up and communicate treatment plans to insurance payors for ongoing authorization.
Ensure prompt communication to management on denials or payor issues.
Work closely with all departments.
Keep accurate records of all transactions and communication with insurances.
Accurately transfer all information to the billing department.
Reports to work as assigned and keep workplace professional.
Maintain acceptable overall attendance.
Attend in-service and educational training as necessary and assigned.
Report personal symptoms of suspected illnesses and contagious diseases to supervisor.
Report incidents, accidents, and occurrences in accordance with policy and procedure.
Maintain safety of the physical environment.
Independently solve problems and follow through.
Perform other duties and tasks as assigned.