Utilization Review Specialist

Duties and Responsibilities

Duties and Responsibilities will include, but may not be limited to:

• Liaise between facilities (clients) and various third-party insurance carriers
• Establish patients’ current insurance information; assist admissions with pre-certification process
• Manage cases via process of initial analysis, concurrent review, collaboration, and consultation for max. Reimbursement
• Collaborate with treatment team to decipher best way to obtain maximum number of treatment days for client
• Communicate with the Verification of Benefits (VOB) team to ensure up to date VOB for every case
• Stay current on clients’ charts to relay client updates and information to insurance carriers
• Collect/provide initial & concurrent reviews of patients’ clinical status for insurance companies based on initial and continued stay care criteria
• Complete insurance/review documentation in a timely manner; facilitate insurance reviews with respective UR depts.
• Collect and submit data to objectively identify patterns of intervention which result in desired patient outcomes
• Advocate for patients’ continued treatment per medical necessity; interface with attending physicians, providers, therapists, and admissions for recommendations on patients’ care
• Assist treatment team with discharge planning, referrals, and patient care/crisis intervention
• Communicate with peers, medical/clinical team members, and physicians via appropriate org structure/channels
• Interact with patients’ families and/or significant others and with facilities and accounts in a professional manner
• Demonstrate clinical competency; observe confidentiality of patient information and HIPAA regulations
• Adapt to changes positively, work as a team member, and collaborate with other disciplines in provision of care
• Attend assigned and/or mandatory in-services and staff meetings; read and initial meeting minutes if missed
• Identify performance improvement opportunities and participate in quality improvement 

Minimum Requirements

KNOWLEDGE

• RN or LVN license preferred
• Experience working with insurance companies and utilization review
• Two years’ experience in mental health and/or drug and alcohol treatment facilities preferred
• Working knowledge of the 12 steps of recovery
• Familiar with EMR (electronic medical records) systems such as (Kipu, Best Notes, Alleva, Medical Mine, etc.)
• Proficient with MS Office Suite (spreadsheets, word processing, email, etc.)

SOFT-SKILLS

• Enjoys working in a collaborative environment
• Works with a sense of duty – values strong attention to detail
• Works with a sense of urgency as these documents are often time-sensitive
• Ability to multitask, prioritize, and remain organized
• Excellent interpersonal skills and strong communicationy A desire to help people in a meaningful wa