Utilization Specialist- OMY

WES Health System•Philadelphia, PA

4d•Onsite

About The Position

The Utilization Reviewer Specialist plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position blends strong relationship-building skills with clinical expertise to navigate complex payer requirements, streamline the authorization process, and support members' and participants' transitions. This role drives the authorization process by reviewing prospective, retrospective, and concurrent Psychiatric Rehabilitation documents to secure prior authorizations by partnering with the relevant managed care team to complete concurrent review authorizations. Acting as a navigator and liaison between the OMY program and the managed care team, the Specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders.

Requirements

Participant-focused and team-oriented.
Strong interpersonal and communication skills.
Flexible in the face of sudden changes in workload, emergencies, or staffing.
Dependable.
Strong problem-solving skills.
Focused on compliance and performance quality.
Bachelor's degree in human services or care management field.
Two years' work in mental health or social services area.
Familiarity with EHR systems.
Knowledge of Psychiatric Rehabilitation regulations.
Knowledge of ASAM criteria, and medical necessity criteria.
Proficient knowledge of Microsoft Office (Excel, Word, PowerPoint).
Ability to express complex information in a clear and concise manner.
Strong critical thinking, analytical, and problem-solving skills.
Highly organized and strong attention to detail.
Relationship builder.
Clinical care coordinator.
Creative problem solver.
Excellent oral and written communication skills.
Detail-oriented and able to complete a high volume of documentation in a fast-paced environment.
Strong computer skills.
Internet research abilities.
Ability to work independently and as part of a team.
Knowledge of mental health system and support.
Must be available for local travel.
Participation in on call coverage as applicable.
May be required to report to work during emergencies including inclement weather.

Nice To Haves

Previous utilization experience preferred with managed care organization systems.

Responsibilities

Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, day authorized, and authorization numbers.
Coordinates reviews, appeals, and maintains denial logs.
Consults with appropriate treatment team members for clarification of documentation as needed.
Assist in identifying patterns of mis-utilization.
Participates in continuing education to reach professional growth objectives, including maintenance of credentials, certifications, and attending case conferences for clinical/psychiatric rehabilitation updates.
Maintains and communicates authorization information to all team members.
Monitor charts medical records in database) for high-quality documentation when needed on a regular basis, regardless of reviews required.
Educates new staff members about Medical Necessity/Psychiatric Rehabilitation Necessity criteria, high-quality documentation, and insurance needs.
Develops relationships and rapport with payers and third-party insurance reviewers.
Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Consideration grids.
Coordinates and facilitates pre-admission Prior Authorizations for participants from referral sources.
Coordinates scheduling with Intake services for transitions in services and/or to other levels of care.
Cross trains with Psychiatric Rehabilitation Intake Specialist for continuity of care and services delivery.
Performs other duties and special projects as assigned.