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Clinical Utilization Review Expert
2 months ago
The Clinical Utilization Review Expert plays a critical role in evaluating and overseeing clinical documentation and medical records to ensure compliance with medical necessity standards for various levels of care. This position involves collaboration with medical and clinical personnel to prepare necessary documentation for insurance providers to secure ongoing authorizations.
Key Benefits
At Aftermath Billing, we recognize the value of our team members and strive to provide a comprehensive compensation package that reflects this. Our offerings include a competitive salary, exceptional healthcare coverage sponsored by the company, and additional benefits such as company-paid Short and Long Term Disability and life insurance. Employees also have the option to select dental, vision, and supplemental insurance plans.
Core Responsibilities:
- Conduct clinical evaluations for medical necessity based on evidence-based guidelines, organizational policies, and recognized clinical criteria.
- Perform pre-certification assessments and manage appeals processes.
- Execute retrospective reviews of claims to ensure medical necessity, coding accuracy, and adherence to medical policies and contractual obligations.
- Engage in negotiations with insurance providers to secure optimal care levels for patients based on established criteria.
- Continuously monitor patient progress, advocating for extended care duration and maximizing benefit levels.
Required Qualifications:
- Demonstrated experience in Utilization Review within Behavioral Health and Substance Abuse sectors.
- Familiarity with ASAM, DSM V, and ICD-9/10 coding systems.
- Experience with Kipu, Sunwave, and Collaborate MD is preferred.
Equal Opportunity Employer
