Utilization Reviewer-onsite

4 weeks ago

Roxbury, United States The Dimock Center Full time

**You** are a caring, hard-working individual who thrives in a team environment and is committed to excellence. You have experience in a setting and are comfortable interacting with patients, as well as managing administrative responsibilities.

**The Dimock Center **is a federally qualified community health center that heals and uplifts individuals, families and communities. Our vision is to redefine the model of a healthy community by creating equitable access to comprehensive health care and education. We promote a culture of respect, excellence, equal opportunity, and commitment to our employees and the communities we serve.

Our Behavioral Health Services programs provide residential and outpatient treatment for those struggling with mental illness, developmental disabilities, or substance use disorders. For many individuals, our programs literally save lives.

The Utilization Reviewer in the Behavioral Health department is responsible for obtaining initial and concurrent insurance authorizations for all applicable coverage and for appropriate level of clinical care across the Substance Use Disorder treatment/Behavioral Health spectrum at The Dimock Center.
- This is a 5 days a week onsite position
- Engages in ongoing contact with insurance representatives to provide initial clinical data for pre-certification and concurrent case reviews to ensure authorization of all necessary dates at each level of care
- Reviews all new admissions daily: completes enrollment forms for all clients entering treatment at all levels of care, follows up on pre-certifications that were initiated off-shift; reviews all discharges daily: completes all disenrollment forms
- Communicates information to clinical staff and fiscal services regarding days/services approved, information required for ongoing review, review schedule, denial of stay, and/or appeals
- Documents insurance authorizations accurately in databases and in client charts
- Consults with administrative/clinical staff regarding utilization management-related issues
- Participates in reviews of cases with clinician

Education: LPN, RN, LCSW, 2-4 years experience
- Experience in healthcare/behavioral health settings preferred
- Knowledge of ASAM criteria and co-occurring disorders
- Working knowledge of MassHealth/managed care products
- Knowledge of behavioral health/substance use utilization review process
- Understanding of medical necessity and evidence-based practices
- Able to organize/structure own workload

40 hours a week - Monday-Friday

Compensation between $33 and $42 per hour depending on experience and qualifications.

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