Utilization Review Specialist

We Level Up•Deerfield Beach, FL

1d•$50,000 - $90,000•Onsite

About The Position

Responsible completion of assigned tasks related to preadmission reviews, continued stay reviews, medical necessity requests, and chart audit requests. Supports the organization’s commitment to the principle that providing the most appropriate services, in the least restrictive environment, utilizing proven clinical interventions will lead to the provision of safe and effective care, treatment, or services to meet the individual’s treatment and recovery needs.

Requirements

High School Diploma or equivalent required.
Minimum of 2 years of experience in utilization review services in substance abuse treatment, behavioral health care, or health care.
General knowledge of: Excel, WORD, and Power Point, KIPU, Email, Tablet, and general desktop applications.

Nice To Haves

Associate or Bachelor’s Degree in healthcare related studies preferred.
Professional License or Certification relevant to Degree.

Responsibilities

Completes Preadmission Assessment and/or admission assessment to obtain necessary treatment authorizations.
Works with call center and admission staff to obtain, review, assess, and clarify any data, assessment, and/or information that helps develop a full and clear picture of the client’s issues, problems, challenges, mental status, and medical status that will indicate the appropriate level of care required to treat his/her presenting condition safely and effectively.
Completes Concurrent Reviews as required by payor sources, case management company or other intermediary entity to ensure ongoing communication and preauthorization of services. This level of review will occur as needed throughout the client’s treatment.
Arranges for Peer Reviews as requested will coordinate both internal and external peer review process as needed or requested to ensure proper care, treatment, or services. These services may occur at any time during the client’s treatment.
Coordinate's provision of Letters of Medical Necessity as needed under the following circumstances: Requested by, or to respond to, insurance company Requested by the billing company Identified as important to support billing and/or UR process.
Screens all intake files for documented discharge plan to communicate information to insurance provider as needed. Stays informed of discharge planning issues and changes. Will be available to clinical team, medical team, referral sources, and others as needed to provide guidance and consultation regarding placement criteria, level of care, appropriateness of services, coordination of care, and discharge planning.
Knowledge of Medical Necessity Criteria including ASAM, and other protocols utilized by payor sources.
Knowledgeable of Levels of Care Criteria as defined by the level of medical and clinical supervision or direct care required of that setting. Levels of care offered by the facility include Residential Detox and Residential Treatment.
Coordinates Physician Reviewer or Peer Review calls as needed to perform MD to MD calls as needed.
Participates in Utilization Review Committee or other committees as needed to present trends and issues.
Develops, tracks, and manages Dashboard Reports as needed to track and trend key performance indicators.
Works well with insurance companies, payors, benefits management, case management and other sources to ensure a collaborative relationship.
Strong knowledge of medical terminology and medical record documentation. General understanding of laboratory results, frequently used medications, and other basic medical issues.
Manages discharge dates under the supervision of the manager. Works with operations managers at each facility to assist in smooth transitions for patients.
Aids the UR Manager in assigning precertification to UR Coordinators and UR Associates.
Trains new hires in the UR department and evaluates their performance during probationary period.
Demonstrates competence in one or more of the following areas: Establishing rapport, systematically gathering assessment data, evaluating readiness for treatment and change, and applying accepted diagnostic criteria for substance use disorders. Screening for psychoactive substance toxicity, intoxication, and withdrawal symptoms. Screening for co-occurring mental health conditions.
Supports the organization’s efforts to comply with National Patient Safety Goals related to: Infection prevention Suicide risk assessment Patient identification Medication reconciliation
Performs additional responsibilities as assigned by leadership.
Staff who assess, plan services for, and provide care to individuals with substance use disorders demonstrate the knowledge and skills to: Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for substance use disorders. Screen for psychoactive substance toxicity, intoxication, and withdrawal symptoms. Screen for danger to self or others. Screen for co-occurring mental health conditions. Analyze and interpret assessment data to determine treatment recommendations and clinical priorities. Collaborate with the individual served to formulate mutually agreed-upon, measurable treatment goals and objectives. Demonstrate adherence to accepted ethical, professional, and behavioral standards of conduct. Participate in continuing professional development and ongoing competency training.
Staff who assess, plan services for, and deliver care to individuals with mental health conditions demonstrate the knowledge and skills to: Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for mental disorders. Screen for common symptoms of mental illness and psychiatric instability. Demonstrate working knowledge of general DSM terminology and diagnostic language. Demonstrate understanding of common mental health risk factors. Screen for suicidality, self-harm, and other high-risk behaviors. Analyze and interpret assessment data to determine treatment recommendations and clinical priorities. Collaborate with the individual served to develop mutually agreed-upon, measurable treatment goals and objectives. Demonstrate adherence to accepted ethical, clinical, and professional standards of conduct. Participate in ongoing continuing education and professional development activities.