Utilization Review Specialist

3 weeks ago

Brentwood, United States Promises Behavioral Health Llc Full time

Job Description Job Description Position SummaryThe Utilization Review Specialist applies expertise of payer behavior and clinical guidelines to optimize utilization review (UR) outcomes.Primary Duties & ResponsibilitiesReviews medical records for quality clinical documentation and compliance.Conducts live reviews with payors and level of care chart reviews.Coordinates Peer-to-Peer Review preparation and assists with scheduling.Coordinates, provides guidance and assists with scheduling for Peer-to-Peer (P2P) review preparationReviews medical records documentation for No Authorization Required (NAR) and Self Pay reviews minimally every seven days for medical necessity.Coordinates with Admissions and Verification of Benefit (VOB) team for expected insurance contribution for admission and continued stay.Communicates to relevant parties at the facility and the Corporate Utilization Review Director any issues with benefit coverage or denials, facilitating client notifications as needed.Completes Denial Notification process and maintains the Denial Tracking Log.Documents authorization in the database in a timely mannerParticipates in UR team calls.Prescreens referrals to anticipate authorizations and provides recommendations regarding level of care, services and treatment planningCollaborates with clinical team and prepares and presents complex requests to the payer for determination of level of care and rapid readmissionsCoordinates and documents all concurrent insurance reviews with clinicians and medical team and provides any notices for missing documentationReviews medical records for quality clinical documentation and compliance and provides feedback to licensing, accrediting, and payer requirementsConducts live reviews with payers and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and/or American Society of Addition Medicine (ASAM) to compel authorizationNegotiates clinical authorization outcomes with the payer, collaborating in advance with the primary treating cliniciansEnsures timely and accurate UR responses and reports for daily Flash meetingCommunicates to relevant parties at the facility and the Central Billing Office (CBO) any issues with coverage or denials, billing issues and facilitates client notifications as neededAttends and participates in Treatment Team Meetings as the payer expert to ensure appropriate authorization outcomes and provides ongoing education regarding payer requirementsOther tasks and duties as assignedJob Qualifications and RequirementsEducation:Masters Degree required; Current licensure preferredExperience:1 year of Utilization Review experience2 years of working in a behavioral health settingKnowledge, Skills, and Abilities :Knowledge of screening practices and basic principles, practices and techniques of drug and alcohol intervention.Knowledge of payor medical necessity guidelines, the DSM-5, and ASAM.Ability to analyze medical records documentation and apply criteria and guidelines.Ability to communicate effectively, both orally and in writing; read and interpret written information; write clearly and informatively; edit work for spelling and grammar.Ability to speak clearly and persuasively in positive or negative situations; listen and get clarification; responds well to questions.Knowledge of organization, communication, and interpersonal skills.Ability to exercise judgment to interpret results and communicate appropriate course of action.Ability to work independently, exercise sound judgment, be attentive to detail, and maintain a positive attitude.Ability to maintain confidentiality of all medical, financial, and legal information.Ability to complete work assignments accurately and in a timely manner.Proficient in Microsoft Office.#J-18808-Ljbffr

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