Clinical Review Specialist

3 weeks ago


Knoxville, Tennessee, United States ADDICTION AND MENTAL HEALTH SERVICES, LLC Full time

We are seeking a highly skilled Clinical Review Specialist to join our team at Addiction and Mental Health Services, LLC.

About the Role:

The Clinical Review Specialist will be responsible for coordinating the facility's insurance certification process, including precertification and continued stay reviews, as well as follow-up on all insurance denials, appeals, and reconsiderations.

Key Responsibilities:

  • Perform pre-admission certification reviews, continued stay reviews, appeals, denials, and/or reconsiderations and provide information to the appropriate review agency or insurance company.
  • Maintain an 'UR Activity Log' which records every review for the facility with financial classification and U.R. information/activity.
  • Maintain a 'call back' calendar for continued stay reviews and maintain a U.R. file for each patient.
  • Document, in the patient electronic record software, the review with the managed care organization, including the level of care requested, the status of the request, outcome, and information about the next review.
  • Review and maintain all correspondence pertaining to certification, appeals, denials, or reconsiderations, and ensure they are scanned into the patient electronic health record.
  • Complete all Quality Improvement indicators for Utilization Management, data analysis, and reporting.
  • Educate counseling staff regarding data needed to adequately document patient care and educate crisis staff regarding data needed to adequately document intake assessments and managed care criteria.
  • Ability to work in a constant state of alertness to perform the job safely.
  • Ability to work in a cooperative manner with co-workers, managers, clients, and prospective managers.
  • Regular attendance.
  • Any other duties as assigned by supervisor.

Requirements:

  • A current RN, LPC, LMFT, LMSW, or LCSW license is preferred. Two years minimum experience in utilization review is preferred.
  • Must possess good grammatical and communication skills.
  • Must be skilled in Microsoft Office applications and have a working knowledge of office equipment.
  • Must be able to read and comprehend hand-written, printed, and online treatment notes and plans.
  • Must be able to hear and comprehend conversations and instructions.
  • Must be able to continuously sit for approximately 7 hours per 8-hour shift.
  • Must be able to walk within the facility a total of approximately two (2) hours per day.

Compensation: The estimated salary for this position is $55,000 - $65,000 per year, depending on experience.



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