Utilization Review Specialist - Full Time (40 Hours)
About The Position
The Utilization Review Specialist reviews each patient’s care at regular intervals from admission through discharge by evaluating the medical record and collaborating with members of the interdisciplinary team. The purpose of this review is to determine medical necessity, appropriateness of level of care, quality of services, and length of stay. Performance is reflected through patient outcomes, payer compliance, and authorization success. This role participates in interdisciplinary clinical team meetings to discuss active treatment, discharge planning, and ongoing medical necessity requirements for insurance reimbursement. The Utilization Review Specialist gathers and communicates clinical updates requested by health plans in a timely and accurate manner.
Requirements
- Active licensure as LPN, RN, LICSW, or LMHC
- Strong clinical documentation review skills and working knowledge of insurance authorization processes
- Ability to collaborate effectively with clinical teams, physicians, and insurance carriers
- Strong organizational, communication, and time-management skills
Nice To Haves
- Master’s degree in a related field preferred
- Minimum of 2 years of utilization review, care management, or utilization management experience preferred
Responsibilities
- Review medical record documentation to ensure continued stay is medically necessary and appropriate.
- Participate in interdisciplinary treatment team meetings to support treatment planning and discharge coordination.
- Perform timely telephonic clinical reviews with insurance carriers for initial and continued stay authorizations.
- Maintain accurate written and electronic documentation of authorizations and payer communications.
- Attend Utilization Review committee meetings and maintain meeting minutes.
- Communicate utilization review issues and potential denials to the UR Director and physicians in a timely manner.
- Facilitate peer-to-peer reviews with insurance carriers when needed.
- Notify the clinical team and business office of authorization denials or changes.
- Assist with the appeals process for insurance denials and document outcomes.
- Compile and maintain utilization data, including length of stay and discharge metrics, as requested by managed care contracts.
- Communicate payer policy changes or concerns to the UR Director and Hospital CEO.
- Assist the UR Director with data compilation and reporting as needed.
- Facilitate clarification of patient benefits and authorizations for acute and diversionary psychiatric care and related medical services.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
