Utilization Review Specialist
About The Position
As a key member of the Northpoint team, the Utilization Review Specialist is a licensed professional who is responsible for ensuring that clinically appropriate care, discharge, and cost-effective utilization of services are maintained across the treatment continuum at Northpoint. The Utilization Review Specialist, in conjunction with a multidisciplinary team, provides ongoing clinical review of patients served - from admission through discharge. The UR Specialist takes the lead in ensuring that admissions, continued stays, discharges and appeals related to service provision are reviewed and responded to in a timely and clinically sound manner in accordance with policies and procedures. The UR Specialist will serve as a strong and knowledgeable liaison between payers and the clinical care teams, working with the entire multidisciplinary team.
Requirements
- Master’s Degree of Social Sciences or commensurate experience required
- Must hold an active substance abuse or mental health licensure in the state where treatment services are rendered
- Must maintain applicable state licensure requirements at hire, and for the entire duration of employment
- 1+ year of experience in relevant field required
- Must be able to exercise discretion and independent judgment in all areas of job performance including adherence to appropriate professional boundaries and strict confidentiality practices in regard to client activities and documentation
- Able to apply clinical judgment, ethics and accountability to formulate and implement treatment plans and other clinical documentation
- Must hold strong personal boundaries and able to build rapport with patients and staff
- Must understand and adhere to the ethical standards of the respective licensure governing board
Nice To Haves
- Excellent critical thinking skills
- Excellent organizational abilities
- Excellent communication skills; ability to communicate clearly and concisely, verbally and in writing
- Quickly and effectively identify and resolve problematic situations
- Comfortable analyzing information and dealing with complexity
- Attention to detail and accuracy
- Able to handle confidential material in a reliable manner
- Ability to interact and communicate with individuals at all levels of organization
- Ability to perform several tasks concurrently with ease and professionalism
- Ability to effectively prioritize workload in a fast-paced environment
- Proficiency with Microsoft Office Suite
Responsibilities
- Apply utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review
- Communication to third-party payers for initial and concurrent clinical review
- Review patient charts to ensure patient continues to meet medical necessity
- Document actions and information shared with care team members or third-party payer
- Alert and discuss with clinical care team and management staff when patient no longer meets medical necessity criteria for the inpatient stay
- Refer to management staff any case that surpasses expected LOS, expected cost, or over/underutilization of resources
- Perform verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per contractual obligations as applicable
- Collect data on variances in LOS, lost days, costs/barriers to discharge/transition and denied days
- Prepare appeals on denied cases when appropriate
- Able to interact and communicate effectively with patients, families, payers, and staff in a concise and descriptive manner both verbally and in writing
- In-depth knowledge of disease process, medical terminology, ASAM dimensions, and utilization review
- Exposure and use of nationally recognized criteria used to determine medical necessity
- Adhere to all company policies and procedures
- Maintain confidentiality in accordance with established policies and procedures and standards of care
- Perform other job-related duties as assigned
Benefits
- Subsidized Health Insurance Coverage for Employee, Spouse, & Dependent(s)
- 100% Employer Paid Basic Life Insurance equal to 1x annual salary, up to $100,000
- 100% Employer Paid Employee Assistance Program
- Voluntary Dental, Vision, Short-Term Disability, Supplemental Life & AD&D, Critical Illness, Accident, and Hospital Indemnity Insurance.
- Pre-tax Savings Accounts for all IRS-allowable medical and dependent care expenses
- Generous Paid Time Off plan
- Employee Referral Bonuses
- 401K Retirement Plan & Employer Match
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
