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Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.
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Insurance Utilization Reviewer jobs near you

Utilization Review Assistant

Odyssey House

Manhattan, NY • On-site

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 29 days ago

Job description

Utilization Review Assistant

Under the direction of the Coordinator of Utilization Review, the Utilization Review Assistant will provide support with filing, tracking, scheduling, and internal/external communications to the Utilization Review team. Utilization Review Assistant documents all updates on authorizations in the electronic medical record, including communications with insurance companies, requests for clinical updates, denials received, and others as needed. Utilization Review Assistant manages discharges across all 820 programs. Participates in collaborative calls with MCOs to confirm client's engagement in treatment. Assists in managing all work queues assigned to Utilization Review to ensure timely follow up on accounts.

Specific duties and responsibilities include:

  1. Manages discharges across all 820 programs; confirm discharge documentation was received and processed accordingly by managed care organizations.
  2. Participates in collaborative calls with MCOs to confirm client's engagement in treatment.
  3. Uploads admissions LOCADTR, concurrent review LOCADTRs and pertinent UR documentation such as legal mandates, MCO correspondence, and discharge documentation to be filed in the department SharePoint and the electronic health record.
  4. Receive, track, and distribute information from MCO case management staff for client's receiving enhanced benefits plans such as HARP.
  5. Track and maintain MCO correspondence on SharePoint for intradepartmental use.
  6. Retrieves voicemails and faxes for the department and transcribes the information into the team calendar and team SharePoint.
  7. Schedule live reviews & peer to peer sessions for Coordinator of UR and relevant parties.
  8. Produce UR meeting minutes and distribution to relevant parties.
  9. Prepare, file, and submit monthly updates on the progress of identified projects, rosters, retention and reports as needed.
  10. Attend regularly scheduled staff meetings and case conferences.
  11. Communicate in a positive, professional manner at all times
  12. Attend all required in-service training seminars.
  13. Other relevant duties as required.

Requirements include:

  1. High School Diploma or GED, with 3 years' experience in an administrative support role in a healthcare setting; Or associate degree in healthcare/Business Administration or Related (Required).
  2. Highly organized and ability to manage multiple projects and priorities to meet deadlines and revenue goals.
  3. Communicate effectively, both orally and in writing.
  4. Ability to work within the context of a multi-disciplinary team, build relationships and foster partnerships.
  5. Proficiency with computer operation (Microsoft Word, Excel, Electronic Health Records, and Outlook programs).

In addition, Odyssey House offers our Utilization Review Assistant:

  • A 35-hour work week (as opposed to a 40-hour work week)
  • Vacation Plan and Holiday Schedule
  • Life Insurance
  • Medical Insurance (Two Plans)
  • Dental and Vision Insurance
  • Additional Insurance Coverages (hospitalization, accidental, critical illness coverage)
  • Long-Term & Short-Term Disability
  • Flexible Spending Account/Health Reimbursement Account
  • 403(b) Plan
  • Corporate Counseling Associates (CCA) EAP benefit
  • Ability Assist Counseling Services (through The Hartford)
  • Commuter Benefits
  • Educational Assistance Programs
  • Special shopping discounts through ADP Marketplace and PlumBenefits
  • RUFit?! Fitness Program
  • Pet Insurance
  • Legal Assistance
  • Optum Financial Service through ConnectYourCare
  • Benefit Advocacy Center through Gallagher

Odyssey House is an equal opportunity employer maintaining a non-discriminatory policy on hiring of its personnel. Odyssey House, and its operational divisions, will not discriminate against any employee or applicant because of race, creed, color, national origin, sex, disability, marital status, sexual orientation or citizen status in all employment decisions including but not limited to recruitment, hiring, upgrading, demotion, downgrading, transfer, training, rate of pay or other forms of compensation, layoff, termination and all other terms and conditions of employment.

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