Clinical Utilization Review Specialist

24 hours ago


Willow Grove, Pennsylvania, United States Progressions Full time
Job Summary

Progressions is seeking a highly skilled Clinical Utilization Review Specialist to join our team. As a key member of our healthcare team, you will be responsible for conducting continued stay reviews of medical record documentation using pre-established criteria and providing updated progress reports to third-party payers to receive certification for payment.

Key Responsibilities
  • Maintain accurate and thorough work logs of all reviews conducted, emphasizing documentation of service, days authorized, and authorization numbers.
  • Perform concurrent continued stay reviews using pre-established criteria, understand ASAM criteria, and communicate this information accurately to insurance carriers.
  • Consult with appropriate treatment team members for clarification of documentation as needed.
  • Exchange information with the Finance Office concerning insurance company requirements and all policies pertaining to certifications and appeals, and input data accurately for financial purposes.
  • Maintain accurate review sheets of all reviews performed.
  • Help the supervisor and departments identify patterns of mis-utilization.
  • Respond to telephone messages quickly, professionally, and appropriately.
  • Participate in continuing education to reach professional growth objectives by attending in-services and other training opportunities.
  • Participate in task forces and committees as assigned.
  • Attend case conference for clinical updates.
  • Maintain and communicate authorization information to all team members.
  • Monitor/flag charts for high-quality documentation when needed on a regular basis, regardless of reviews required.
  • Educate new staff members about ASAM criteria, high-quality documentation, and insurance needs.
Qualifications
  • Bachelor's degree (BA) in Behavioral Health or licensed as a Nurse (RN/LPN).
  • Knowledge of 12-step recovery and an understanding of chemical dependency.
  • Knowledge of facility systems and organization as they pertain to medical records and organization review.
  • Knowledge of medical terminology and medical record format and content.
  • Excellent computer, internet, and business software skills.
  • Excellent customer-facing and phone skills.
  • Communication and interpersonal skills to develop relationships with patients, staff, and providers.
  • Strong organization skills with a proven ability to multi-task and manage time to meet frequently changing deadlines in a fast-paced environment.


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