Utilization Review Specialist (48581)

WESTCARE INC•Henderson, NV

8d•$25 - $25

About The Position

Person in this position is responsible for collecting clinical information and communicating with MCOs in a timely manner in order to advocate for the highest level of care that is supported by the clients acuity, and in compliance with regulations as defined by WestCare and its regulatory and accrediting agencies. Person in the position is also responsible for communicating with insurance companies/payor sources as an advocate for the patients served. Essential functions include those listed below

Requirements

Proven experience in conceptualizing a case and creating a clinical impression to present to all involved and approved parties, including managed care representatives
Knowledge of CPT, ICD 9 & ICD 10 coding, ASAM, medical terminology and EMR/CDS Systems.
Proficiency in Microsoft Office Platform Applications and knowledge of HIPAA regulations and guidelines.
Knowledge of managed care and reimbursement principles.
Understanding and proficiency in State of NV Medicaid Chapter requirements
Collaboration, negotiation, and assertiveness skills.
Must be organized, detail oriented and have the ability to focus on several job-specific tasks with several potential surrounding distractions and patient traffic.
Excellent verbal and written communication skills.
Critical thinking and problem solving skills.
Must be able to work in a team environment.
Ability to perform complex tasks and to prioritize multiple projects.
Strong analytical and critical thinking skills and the ability to analyze, summarize, and effectively present data.
Ability to work collaboratively with others in a manner that is pleasant and professional.
Ability to exercise good judgment and discretion.
Ability to operate a computer and complete documents in Microsoft program formats.
Ability to complete work tasks within scheduled work hours.
Excellent verbal and written communication skills.

Nice To Haves

Associates or Bachelors level LPN or RN and/or Bachelors or Masters level CADC/LADC with 2 years utilization review experience, preferred experience working with individuals with psychiatric or substance use disorder

Responsibilities

Establish and maintain positive and frequent effective communication with insurance carriers
Read and understand patient/members running chart narrative and respective case notes and be able to disseminate patient needs and professional/clinical recommendations and communicate this information effectively
Call in intakes and/or peer to peers and get the patients appropriate level of care authorized
Obtain and communicate level of care and authorizations and properly enter information into the systems.
Manually complete and submit quality authorization documentation to insurance companies
Serve as an advocate for patient members in relation to their care and their insurance benefits
Responsible for tracking current & concurrent authorization needs in all levels of care
Responsible for detailed system documentation of accounts
Communicating with other departments to obtain or provide needed information on patient accounts.
All other related duties as assigned