Utilization Review Specialist - (40 hours 8a-4p) - Remote
About The Position
The Utilization Review Specialist performs pre-certification and concurrent clinical utilization reviews with insurance companies in accordance with the certification requirements of each patient’s insurance plan. The position requires daily communication with Patient Financial Services to help ensure that every patient is covered for their stay, as well as experience working with interdisciplinary treatment teams. The specialist consults with clinical staff on intervention strategies and continued-care authorizations, assists staff with care coordination, prepares cases for physician-to-physician reviews when needed, and documents authorizations and review results in the computer system. The role also communicates insurance benefits and review expectations to treatment teams, supports coordination of aftercare, and informs managed care providers about alternative levels of care within the Gosnold system.
Requirements
- Bachelor’s degree in nursing, social work, psychology, mental health, or addiction.
- At least two years of clinical experience delivering health services.
- Knowledge of clinical criteria for various levels of care.
- Computer literacy and ability to learn and use behavioral health software programs.
- Good communication, interpersonal, and organizational skills.
- Experience working on interdisciplinary treatment teams.
Nice To Haves
- Experience performing utilization review and/or providing clinical services in an intensive treatment setting.
- Working knowledge of managed care principles.
- Experience in behavioral health.
Responsibilities
- Perform pre-certification and concurrent clinical utilization reviews with insurance companies in accordance with each patient’s insurance plan requirements.
- Communicate daily with Patient Financial Services to help ensure patient coverage for the duration of the stay.
- Consult with clinical staff to coordinate intervention recommendations and authorizations for continued care.
- Provide technical assistance to staff with care coordination activities as needed.
- Prepare and present cases to physicians when doctor-to-doctor reviews are necessary.
- Document and record authorizations and utilization review results in the computer system.
- Report review progress and expectations for the next utilization review to treatment teams.
- Educate treatment teams about members’ insurance benefits and help coordinate comprehensive aftercare.
- Inform managed care providers about alternative levels of care within the Gosnold system and promote these services accurately.
- Perform other duties as assigned.
Benefits
- Blue Cross & Blue Shield health and dental insurance
- Vision insurance
- Medical and dependent care flexible spending accounts
- Paid vacation, sick, and holiday time
- 403b retirement savings plan with employer match
- Personal financial management services
- Life and supplemental life insurance
- Critical illness and accident insurance
- Employee Assistance Program
- Pet insurance
- Tuition assistance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
