The primary responsibility of the Utilization Review Specialist is to review medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, authorizations and denials for patients. The UR Specialist is responsible for contacting external case managers/managed care organizations for certification and recertification of insurance benefits throughout the patients stay, and assists the treatment team in understanding the insurance companys requirements for continued stay and discharge planning. The UR Specialist is responsible for having a thorough understanding of the patients treatment through communication with the treatment team. The UR Specialist advocates for the patients access to services during treatment team meetings and through individual physician contact. The UR Specialist chairs treatment team meetings and continued stay reviews as indicated.
Associates Degree preferred
Minimum Work Experience
The person holding this position should have at least two (2) years Utilization Review experience preferably in a behavioral/psychiatric healthcare setting or similar type of organization.
Current California LVN license