Utilization Review Specialist/Behavioral Health Substance Abuse
The Utilization Review Specialist is responsible for all aspects of the authorization of treatment via insurance and managed care companies. The Utilization Review Specialist provides appropriate client information to third party payers regarding the medical necessity of treatment in a timely manner. The Utilization Review Specialist will also perform pre-certification reviews, concurrent reviews and will perform appeal reviews as needed.
- Act as agency liaison with insurance and managed care companies for authorization of treatment costs, representing company in a positive manner in the professional Participate in staff meetings as needed
- Clear communication with supervisors, co-workers, and facilities
- Keeps abreast of changes to, and monitors compliance with, State and Federal laws and regulations in areas of insurance/ third party payers
- Protects the confidentiality of patients and the privacy of staff
- Uses a computer to type correspondence, reports and other items as requested, ensuring that typing is accurate
- Process data in conjunction with compliance consultant in order to present it effectively using established statistical methods
- Demonstrates the willingness to accept responsibility
- Performs other duties as assigned by the Director of Utilization Review
- Prior Utilization Review experience in a Substance abuse environment is mandatory.
- Knowledge of ASAM guidelines.
- Knowledge of accreditation and licensure requirements (RN, LCSW, LPN, LMFT) in accordance with state agencies.
- Ability to establish rapport with and supervise employees as well as professional staff and peers
- Ability to work under stressful conditions and is flexible in relation to department needs.
- Knowledge of medical terminology.
- Demonstrates proficiency in Verbal & Written Communication
- Knowledge of State & Federal Statutes Regarding Patient Confidentiality Laws.
- Knowledge of Drug-Free Workplace Policies. Knowledge of Corporate Integrity & Compliance Program.
- Knowledge of state guidelines and accreditation agency standards
- KIPU experience required, Best Notes experience a plus
- Ability to lift a minimum of 20 lbs.
EXPERIENCE: Three to Five (5) years experience in Case Management/Utilization Review (as either CADC, LAADC, RN, LCSW, LPN, LMHC, LMFT, RN Case Manager, or Utilization Review Coordinator).