Utilization Review Specialist

KVC Health Systems•Webster Groves, MO

1d•Onsite

About The Position

The Utilization Review department carries with it the responsibility of managing those aspects of a patient stay that relates to the initial, concurrent and discharge interface with health plans. This role will be in frequent contact with health plans providing clinical information developed from the treatment team and staff working with the patient and family. This job is one of detail and accuracy in a very fast environment. This position is a part of the treatment team and is the primary contact with the health plan. This includes coordinating with the KVC Admissions Department, physicians, nurses and therapists to ensure timely, accurate and complete assessments are performed on children and youth, and adults, and making appropriate referrals for placement and services based on the assessment.

Requirements

High school diploma or general education degree (GED) from an accredited institution required.
Valid driver’s license and auto insurance.
A minimum of two years’ experience working in case management, utilization review, wellness coordination with at least one of those years of experience working with economically disadvantaged, vulnerable or at-risk youth and/or adults.
Intermediate skills in Microsoft Office Suite, including Word, Excel, and Outlook email.
Strong interpersonal skills, including oral and written communication.

Nice To Haves

Bachelor’s degree in a human services field (I.e., social work, education, sociology, psychology, counseling, applied behavioral sciences) or criminal justice preferred.

Responsibilities

Practice conduct that displays respect for all KVC colleagues and community stakeholders regardless of age, gender identity, sexual orientation, race, religion, ethnicity, or veteran status
Work effectively with a wide range of constituencies, including but not limited to a multi-disciplinary internal team, external stakeholders, referral sources, other care providers, and insurance companies in a diverse community
Ensure and monitor correct data is in electronic health records with authorizations/child specific contracts (single case agreements, etc.)
Assisting in mapping out contractual relationships, maintaining good relationships with these contracts and external agencies
Gathers data and compiles information completely and accurately and enter data into the data management systems
Conducts Utilization Review functions; reports to insurance companies; files appropriate forms and writes appeals for signature
Gathers and summarizes information for intake assessments and discharge summary reports
Maintains strictest confidentiality about child/youth/adult/family information
Assists in maintaining compliance with state, federal and The Joint Commission guidelines
Will assist with completion of paperwork for admissions and assist in other duties
Will assist with individual assignments such as audits of meaningful use data
Attend staff conferences and in-service training as required or needed
Provide reviews of documentation to enhance quality of records and ensure compliance with standards of care
Support special initiatives through quality assurance roles to enhance services for consumers