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Clinical Utilization Review Specialist

2 months ago

Fort Lauderdale, Florida, United States ICBD Holdings LLC Full time
About ICBD Holdings LLC

ICBD Holdings LLC is a leading provider of medical billing services, specializing in the substance use disorder, mental health, and autism fields of healthcare services.

Job Summary

We are seeking a highly skilled Clinical Utilization Review Specialist to join our team. As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources.

Key Responsibilities
  • Clinical Documentation Review: Evaluate and analyze medical records, treatment plans, and clinical documentation to ensure accuracy and compliance with established standards.
  • Collaborate with Healthcare Providers: Work closely with healthcare providers to gather additional information or clarification on documentation when necessary.
  • Live Reviews: Participate in live reviews with BSBAs and other health professionals to ensure comprehensive reviews.
Utilization Review:
  • Assess Appropriateness: Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies.
  • Identify Potential Issues: Identify and communicate potential issues related to overutilization or underutilization of services.
Collaboration and Communication:
  • Interdisciplinary Teamwork: Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews.
  • Clear Communication: Communicate findings and recommendations clearly and effectively to internal teams and external stakeholders.
Quality Improvement:
  • Process Improvement: Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery.
  • Feedback and Suggestions: Provide feedback and suggestions for process improvements based on review findings.
Regulatory Compliance:
  • Regulatory Knowledge: Stay informed on relevant healthcare regulations, guidelines, and accreditation standards.
  • Compliance: Ensure compliance with all applicable laws and regulations in the utilization review process.
Requirements
  • Knowledge and Ability: Knowledge and ability to communicate medical necessity using medical dialect.
  • Assessment and Authorization: Complete assessments, pre-certifications, initial authorizations, re-authorization, peer reviews, and appeals.
  • Insurance Advocacy: Advocate on the client's behalf to ensure services will be covered by insurance company.
  • EMR Management: Ensure EMR is up to date and accurate in regards to UR.
  • ABA Guidelines: Knowledge in ABA guidelines and criteria to identify and advocate for appropriate care placement.
  • Documentation Review: Monitor clinical documentation to ensure appropriate, timely, and effective provision of services and treatment planning.
  • HIPAA Compliance: Ability to adhere to HIPAA compliance standards.