Utilization Review Senior Specialist

5 days ago


Philadelphia, United States Nextus Billing Solutions Full time

Job Summary

The Utilization Review Senior Specialist plays a crucial role in obtaining authorizations by performing a variety of functions which incudes, but not limited to, navigating electronic medical records and advocating for the patient; communicating with insurance carriers via phone/ fax as needed and articulating medical necessities using specialized language while strictly adhering to compliance standards.

Responsibilities and Duties

  • Evaluate and prepare medical records to justify medical necessity
  • Advocate on the client(s) behalf to ensure services will be covered by insurance company
  • Ability to adhere to HIPPA compliance standards
  • Ability to articulate medical necessity using medical dialect
  • Proficient in personal time management, multi-tasking and calendar organization
  • Complete new admissions and concurrent reviews in a timely manner
  • Review clinical information and communicate documentation needs
  • Establish and maintain professional relationships with care managers

Qualifications and Skills

  • Proficiency with the utilization review process
  • In-depth knowledge of the Substance Abuse Facility utilization review process and/or In-depth knowledge of Mental Health utilization review process
  • Familiar with ASAM / and or medical necessity criteria for each level of care
  • Effective communication skills, both verbal and written via phone and email
  • Proficiency utilizing related software programs such as Kipu, ZenCharts, etc.
  • Microsoft Office products including Word, Excel, and Power Point
  • Knowledge in computers and can navigate various software programs

Education and Experience

  • Experience conducting utilization reviews in healthcare setting
  • Experience working in mental health or behavioral healthcare setting
  • High-school diploma

(Preferred but not required):

  • Bachelor’s degree or higher in Psychology or related field
  • Licensed Mental Health Clinician (LCSW, LMHC, LMFT)
  • Certified Addiction Counselor or Professional (CAC, CAP, MCAP, MAC)
  • Experience working in a medical billing setting
  • Experience working in Substance Abuse Treatment Industry
  • Experience managing caseloads of 50+ per week
  • Experience obtaining an average of 200 authorizations per month
  • Knowledge in day-to-day operations of a psychiatric or behavioral healthcare setting
  • Comprehensive knowledge of all levels of care (Detox, RTC, PHP, IOP, OP, Aftercare)



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