Nextus Billing Solutions | Utilization Review Senior Specialist | philadelphia, pa
7 days ago
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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philadelphia, United States Nextus Billing Solutions Full timeJob SummaryThe 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...
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Utilization Review Senior Specialist
7 days ago
Philadelphia, United States Nextus Billing Solutions Full timeJob SummaryThe 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...
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