Utilization Review Specialist
About The Position
The Utilization Review Specialist proactively monitor utilization of services for patients to optimize reimbursement for the facility. You will assess patient care plans to ensure appropriate and cost-effective treatment, advocating for quality care while managing healthcare resources. At Bayside Marin drug and alcohol addiction treatment center, we take pride in the expertise and dedication of our staff. Our therapists and counselors were carefully selected because of their skill level, passion for their field of expertise and their commitment to clinical excellence. All of our staff is knowledgeable about recovery, and many have years of personal recovery themselves. Due to the varied background and extensive training of our team we are able to respond to the diverse challenges that our clients face. Our staff is the heart and soul of our drug rehabilitation program. You won't find a more passionate, experienced and skilled group of professionals who work closely to ensure a personalized and empowering treatment experience for every client. We treat each client as an individual, and tailor our treatment plans to address the specific challenges that pose a threat to long-term recovery. We recognize that in treating addiction and co-occurring disorders, we're doing much more than treating a diagnosis - we are treating people, each with their unique needs, backgrounds and belief systems.
Requirements
- Required Education: High school diploma or equivalent.
- Experience: Clinical experience is required, or two or more years' experience working with the facility's population.
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
- First aid may be required based on state or facility requirements.
Nice To Haves
- Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
- Previous experience in utilization management is preferred
- Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
Responsibilities
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between facility and external organizations.
- Initiate and complete the formal appeal process for denied admissions or continued stay.
- Assist the admissions department with pre-certifications of care.
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
- Perform other functions and tasks as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Industry
Ambulatory Health Care Services
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
