Job Description

Utilization Review Specialist

The Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine the legitimacy of admission, treatment, and the length of stay and interfaces with managed care organizations, external reviewers, and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to managed care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.

Qualifications:

• Education: Bachelor's degree required. Master's degree preferred.
• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
• License: Current unencumbered clinical license strongly preferred.
• Additional Requirements: CPR certification and Crisis Prevention Training preferred. May be required to work flexible hours and overtime.

Job Responsibilities:

• Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services.
• Completes pre and re-certifications for inpatient and outpatient services. Reports appropriate denial, and authorization information to designated resource.
• Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
• Participate in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
• Works with DON to ensure documentation requirements are met.
• Ensure appeals are completed thoroughly and on a timely basis.
• Interface with managed care organizations, external reviews, and other payers.
• Communicate with physicians to schedule peer to peer reviews.
• Accurately report denials.

Physical, Mental, and Special Demands:

• Ability to sit and stand (at least two-thirds of the shift) and walk (possibly one-third of the shift).
• Ability to reach above, or below waist height, kneel, bend, stoop, turn, and twist (occasionally to frequently).
• Visual ability to read charts, treatment plans, financial documents, computer screen and typewritten materials.
• Ability to frequently push/pull wheeled carts to 100 pounds.
• Ability to frequently lift and carry 10 lbs.; occasionally 20 to 50 lbs.
• Ability to work in an environment where chemicals are frequently used for cleaning, where medical and electrical hazards may be present and where dust, mist and steam are frequently generated in housekeeping tasks.
• Ability to work at a rapid pace and perform a variety of repetitive duties.

Job Tags

Similar Jobs