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Clinical Utilization Review Specialist
2 months ago
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 conferences 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.
- Work in an environment with risk of exposure to communicable disease and possible exposure to intoxicated, disruptive, and/or agitated patients.
- Perform other duties as assigned.
- 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.
