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Utilization Review Specialist

Crossroads Treatment Centers Greenville, SC
  • Posted: 28 days ago
  • Other

Crossroads Treatment Centerswas founded on May 5, 2005 to serve a patient population with opioid addiction. Since its founding in 2005, the company has grown rapidly and now includes 80+ treatment centers in 10 states. Each member of the Crossroads team specializes in an area that supports the recovery of over 20,000 patients. Crossroads' clinical staff includes physicians, pharmacists, counselors, nurses, and other service coordinators. Along with medication management, our staff works closely with each patient to create an individualized treatment plan aimed at building recovery and relapse prevention skills.

Crossroads Treatment Centers is seeking a Utilization Review Specialist for our center located in Greenville, South Carolina.This position is responsible for activities related to authorization and maintenance of therapy service related to insurance benefits and compliance monitoring of billable activities.

Job Duties and Responsibilities:

  • include the following and other duties that are assigned.
  • Works closely with Clinical Director, Program Director, Regional Specialist and Medicaid Specialist and clinical staff towards compliance monitoring
  • Uses Medicaid Payer existing metrics/tools to track clinical and documentation compliance including standards for care
  • Verifies benefits coverage for new and existing patients via State eligibility system
  • Responsible for submitting treatment authorizations for new intakes, transfers and re-admissions
  • Tracks authorization status including billable units remaining for timely subsequent re-authorizations
  • Works with Medicaid Payer and Clinical Director to address treatment outcomes for patients who do not meet continued stay criteria
  • Manages paperwork and communication related to requests for Medicaid Payer for step-up/step-down transitions between levels of care
  • Enters patient "flags" in medical record in advance of required counseling and doctor appointments within the first 30 days of treatment in additional to "flags"
  • Requires high proficiency for technology, problem solving and attention to detail
  • Advises Program Director(s) surrounding trends in UR, inefficiencies, unethical practices, etc.
  • Assists the Clinical Director to audit service documentation for clinicians, physician, nursing staff to ensure accuracy of billable services
  • Helps patients navigate circumstances related to the benefits utilization

The most qualified candidates will possess the following:

  • High School Diploma or equivalent.
  • Experience with medical billing and/or Medicaid preferred.
  • Experience with prior authorizations is required
  • Experience working in healthcare or behavioral health setting
  • Experience ensuring patient records/charts are in compliance

Crossroads Treatment Centers

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