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Utilization Review Specialist

3 months ago

Stoughton, United States Gosnold Full time
Job DescriptionJob DescriptionOVERVIEW:

Gosnold, Inc. has been a nationally accredited non-profit leader in the prevention, treatment and recovery of mental health and substance use disorders for over 50 years. We offer a full, end-to-end continuum of care offering a wide range of treatment options. Highly regarded for innovation, we offer a comprehensive patient centered continuum of care tailored to fit the needs of each individual. Gosnold welcomes like-minded individuals who are passionate about our mission to support people and families affected by these disorders, and to promote lasting recovery.

SUMMARY:

The Utilization Review Specialist will perform utilization review of pre-certification and concurrent clinical utilization reviews with insurance companies in accordance with certification requirements of each patient’s insurance plan. This position requires daily communication with Patient Financial Services to ensure that every patient is covered for their stay. The Utilization Review Specialist must have experience working on interdisciplinary treatment teams.

ESSENTIAL JOB FUNCTIONS/DUTIES/RESPONSIBILITIES:
  • Working knowledge of managed care principles with preference for experience in dual diagnosis.
  • Consult with clinical staff to coordinate recommendations for intervention strategies and authorizations for continued care.
  • Provide technical assistance to staff with care coordination activities as needed.
  • Prepare and present cases for physician when necessary for doctor-to-doctor reviews.
  • Document and record authorizations and UR results in the computer system. Record and report to treatment teams the progress and expectations for the next UR review.
  • Daily communication and education with the treatment teams about the member’s insurance benefits and aid them in coordinating the most comprehensive after care for the patient.
  • Provide information to managed care providers about alternative levels of care within the Gosnold system and accurately promotes these services.
  • Perform all other duties as assigned.

MINIMUM KNOWLEDGE, EXPERIENCE, AND SKILLS REQUIRED:

The requirements listed below are representative of the knowledge, skills, and/or abilities required to perform the job.

  • Education: Master’s degree in social work, psychology, mental health or addiction required.
  • Experience: Experience in performing utilization review and/or providing clinical services in an intensive treatment setting is preferred and at least (two) 2 years of clinical experience in delivery of health services. Knowledge of clinical criteria required for various levels of care.
  • Skills: Computer literacy and ability to learn and use behavioral health software programs. Good communication, interpersonal, and organizational skills.

Certificates, Licenses, and Registrations: N/A

BENEFITS (based on full-time employment):

  • Blue Cross & Blue Shield health and dental insurance
  • Vision insurance
  • Medical and dependent care flexible spending accounts
  • Generous paid vacation, sick, and holiday time
  • 403b retirement savings plan with employer match
  • Personal financial management services
  • Life and supplemental life insurance
  • Critical illness and accident insurance
  • Family First caregiver benefit
  • Employee Assistance Program
  • Pet insurance
  • Tuition assistance
  • Payroll deductions for home and automobile insurance

Gosnold is an Equal Opportunity Employer.

COVID-19 Statement:

In accordance with CDC guidelines, Gosnold maintains strict standards when it comes to protecting our staff, patients, and residents, and offers a variety of personal protective equipment to ensure a safe and stress-free workplace.