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Clinical Utilization Review Analyst
2 months ago
The Utilization Review Specialist plays a critical role in overseeing and evaluating clinical documentation and medical records to confirm that medical necessity standards are satisfied for each level of care. This position collaborates with medical and clinical personnel to prepare the necessary documentation for submission to insurance providers for ongoing authorization. The primary goal of our UR Specialist is to streamline the review and approval process, allowing clinical and medical teams to concentrate on delivering exceptional care to clients.
COMPENSATION AND BENEFITS
We recognize that our success is driven by our dedicated team, and we prioritize their well-being.
Our comprehensive compensation package includes a competitive salary, employer-sponsored premium healthcare, gap coverage, and company-paid short and long-term disability insurance along with a life insurance policy. Team members have the option to select dental, vision, and additional insurance benefits.
Key Responsibilities:
- Conducts clinical evaluations for medical necessity for Facilities/Members/Providers utilizing evidence-based guidelines, policies, benefits, and nationally recognized clinical standards.
- Performs pre-certification assessments and appeals evaluations.
- Executes retrospective clinical reviews of claims for medical necessity, coding accuracy, adherence to medical policies, and compliance with contracts.
- Engages in negotiations with insurance companies to secure optimal care levels for patients/clients based on ASAM and other accepted criteria.
- Continuously reviews patient progress, advocating for sustained client care at the maximum duration with the highest level of benefits.
Required Qualifications:
- Demonstrated experience in Utilization Review within Behavioral Health and Substance Abuse.
- Familiarity with ASAM, DSM V, and ICD-9, 10.
- Experience with Kipu, Sunwave, and Collaborate MD is preferred.
Equal Opportunity Employer
