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Job Description: Utilization Review Supervisor

Location: State of Washington – Hybrid or Remote

Position Summary: The Utilization Review (UR) Supervisor will serve as the first point of escalation for payors requiring additional or missing information to support authorization. The UR Supervisor is responsible for ensuring the procurement of authorization upon admission and discharge, accuracy of authorization information, and timely escalation of barriers requiring clinical expertise. This role also assists in coordinating Peer-to-Peer discussions with payors.

Key Responsibilities:

• Collaborate and communicate with payors via phone, fax, or payor portal.
• Submit clinical reviews to payors.
• Provide information to payors supporting admission and continued stay.
• Manage requests submitted from payors.
• Provide discharge dates to payors.
• Submit copies of Utilization Management (UM) activities to payors, as needed.
• Track and monitor requests through Electronic Medical Records (EMR).
• Ensure incoming requests are responded to promptly and accurately.
• Obtain and enter authorization numbers from payors.
• Verify up-to-date concurrent authorizations for in-house patients.
• Review and monitor accounts to ensure proper documentation of benefits and authorizations.
• Support the concurrent denials process.
• Assist in coordinating Peer-to-Peer discussions for Physician Advisors, Medical and Clinical Directors, Registered Nurses (RNs), and Therapists.
• Update patient demographic/patient type/coverage information as needed.
• Communicate with all members of the Interdisciplinary Team (e.g., nurses, physicians, therapists).
• Assist department leadership with quality audits as needed.
• Timely escalate cases requiring clinical expertise.
• Interact with third-party healthcare providers to resolve issues.
• Monitor daily discharge reports to ensure all patient stay days are authorized.
• Maintain a working knowledge of payor contracts and regulatory requirements.
• Adhere to facility policies, procedures, rules, regulations, and laws of federal and state regulatory bodies.
• Communicate and collaborate with other departments to secure necessary information for reimbursement.
• Adhere to HIPAA and 42 CFR regulations by verifying caller authorization level before releasing account information.
• Promote and adhere to core workplace values: kindness, teamwork, empathy, integrity, excellence, and mission.

Qualifications and Knowledge:

• Ability to work independently and as part of a team.
• Proficiency in reading and interpreting documents such as safety rules or policy and procedure manuals.
• Strong verbal and written communication skills.
• Ability to apply common sense understanding to carry out instructions in written, oral, or diagram form.
• Problem-solving skills involving several concrete variables in standardized situations.
• Flexibility in relation to department needs.

Education, Experience, and Skills:

• Bachelor’s degree preferred
  
• 3+ years of experience in utilization review, case management, or discharge planning.
• Experience in a Behavioral Health/Substance Use Disorder (SUD) facility providing multiple levels of care strongly preferred.
• Must have or obtain a current First Aid and CPR card within 30 days of hire.

Work Conditions and Physical Requirements:

• Work Setting: Indoors, environmentally controlled.
• Body Positioning: Prolonged periods sitting at a desk and working on a computer.
• Communication: Contact with others via electronic mail, telephone, video.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.