Utilization Review Specialist
Location
United States
Posted
77 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Utilization Review Specialist
ADDICTION AND MENTAL HEALTH SERVICES, LLC
Role Description The Utilization Review Coordinator plays a critical role in ensuring that patients at our facility receive the appropriate level of care while managing treatment costs. This position involves: - Coordinating, assessing, and authorizing treatment plans. - Collaborating with medical staff. - Maintaining compliance with healthcare regulations. - Working closely with insurance companies, clinicians, and support staff. - Advocating for the best interests of the patients and the hospital. Key Responsibilities - Case Review and Assessment: - Conduct daily reviews of patient charts, treatment plans, and progress notes to determine alignment with clinical guidelines and insurance requirements. - Monitor patient progress, reassess treatment needs, and recommend adjustments in care levels as needed. - Collaborate with clinical teams to understand patient needs, assess treatment efficacy, and make informed recommendations. - Insurance Coordination: - Act as the primary point of contact with insurance providers for treatment authorization, concurrent review, and appeal processes. - Submit required documentation to insurance companies in a timely manner, including clinical updates, to secure and maintain treatment authorization. - Resolve reimbursement issues, advocating for patient treatment needs and securing necessary approvals. - Documentation and Compliance: - Ensure all documentation is complete, accurate, and in line with state, federal, and hospital policies to facilitate compliance and quality audits. - Maintain a working knowledge of current insurance guidelines, DSM-5 criteria, and ASAM (American Society of Addiction Medicine) criteria. - Participate in internal and external audits, preparing records and reports as necessary. - Collaboration and Communication: - Work closely with medical and support staff to ensure continuity of care and that utilization review processes are aligned with patient needs. - Provide guidance to clinical staff regarding documentation best practices and criteria required for continued care authorizations. - Participate in multidisciplinary team meetings to discuss patient care plans, discharge planning, and treatment adjustments. - Quality Improvement: - Identify trends in denied claims or treatment authorizations, providing recommendations for process improvements. - Assist in training hospital staff on utilization review processes, criteria for different levels of care, and effective documentation practices. - Collaborate in developing policies to improve efficiency, patient care outcomes, and financial performance. Qualifications - Bachelor’s degree in Nursing, Social Work, or a related field required. - Master’s degree in a health-related field preferred. - Minimum of 2 years in utilization review, case management, or related field, preferably within a behavioral health or chemical dependency setting. - Current RN, LCSW, or LPC license preferred. - In-depth understanding of mental health, substance abuse treatment and ASAM criteria. - Strong analytical and critical thinking skills with the ability to make clinical judgments based on patient data. - Excellent communication and interpersonal skills to facilitate interactions with insurers, staff, and patients. - Proficiency with electronic medical records (EMR) and utilization review software. - Knowledge of state, federal, and industry regulations related to chemical dependency and mental health care. Working Conditions - Full-time, primarily daytime hours, with occasional on-call duties or weekends as needed. - Must be able to work in a high-paced environment and handle sensitive information with discretion. - Physical demands may include sitting for extended periods, light lifting, and using a computer for most of the workday. Benefits - Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits. - Expanded Coverage – Options for domestic partners and a wider network of in-network providers. - Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching. - Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more. - Student Loan Repayment – Available for nurses and therapists. - Retirement Benefits – 401(k) plan through Voya to help employees plan for the future. - Generous PTO – A robust paid time off policy to support work-life balance. - Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.
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