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Utilization Review Specialist
Location
Philippines
Posted
3 days ago
Salary
$6 / hour
Seniority
Senior
Job Description
Utilization Review Specialist
Remote Raven
• Manage and submit preauthorization requests to insurance providers for clients entering treatment at Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Standard Outpatient (OP) levels of care. • Ensure all required documentation is complete and accurately reflects the clinical needs of the client. • Communicate with insurance companies to secure timely approvals for necessary services. • Negotiate and manage Single Case Agreements with insurance providers for clients needing services outside of network coverage. • Monitor ongoing treatment needs and submit continued authorization requests for Residential, PHP, IOP, and OP levels of care to ensure uninterrupted client care. • Collaborate with the clinical team to ensure a comprehensive understanding of each client when asking for continued authorization. • Attend regular meetings with clinical staff to discuss client progress, treatment plans, and authorization needs. • Act as a liaison between clients, clinical teams, and insurance providers to advocate for the necessary care. • Ensure all utilization review activities comply with relevant regulations, insurance policies, and organizational standards.
Job Requirements
- Education: Bachelor's degree in healthcare administration, social work, or a related field is preferred.
- Experience: At least 3-5 years of experience in utilization review, medical billing, or a related field, preferably in a behavioral health setting.
- Skills:
- Strong understanding of insurance authorization processes, including preauthorization, continued authorization, SCAs, and multiple levels of care.
- Excellent communication and negotiation skills with the ability to advocate effectively for client needs.
- Proficiency in electronic medical records (EMR) systems and documentation standards.
- Ability to collaborate with clinical staff and provide training on complex topics in a clear and supportive manner.
- Detail-oriented with strong organizational and time-management skills.
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