Utilization Review Specialist

Position Summary

The Utilization Review Specialist applies expertise in payer behavior and clinical guidelines to optimize utilization review (UR) outcomes. 

 Primary Duties & Responsibilities

• Reviews medical records for quality clinical documentation and compliance.
• Conducts live reviews with payors and level of care chart reviews.
• Coordinates Peer-to-Peer Review preparation and assists with scheduling.
• Coordinates, provides guidance and assists with scheduling for Peer-to-Peer (P2P) review preparation
• Reviews medical records documentation for No Authorization Required (NAR) and Self Pay reviews minimally every seven days for medical necessity. 
• Coordinates with Admissions and Verification of Benefit (VOB) team for expected insurance contribution for admission and continued stay.
• Communicate with relevant parties at the facility the VP of Revenue Cycle, the Corporate Utilization Review Director, Utilization Review Manager and RCM team any issues with benefit coverage or denials, facilitating client notifications as needed.
• Completes Denial Notification process and maintains the Denial Tracking Log.
• Documents authorization in the database in a timely manner
• Participates in UR team calls. 
• Prescreens referrals to anticipate authorizations and provides recommendations regarding level of care, services and treatment planning
• Collaborates with clinical team and prepares and presents complex requests to the payer for determination of level of care and rapid readmissions
• Coordinates and documents all concurrent insurance reviews with clinicians and medical team and provides any notices for missing documentation
• Reviews medical records for quality clinical documentation and compliance and provides feedback to licensing, accrediting, and payer requirements
• Conducts live reviews with payers and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and/or American Society of Addition Medicine (ASAM) to compel authorization
• Negotiates clinical authorization outcomes with the payer, collaborating in advance with the primary treating clinicians
• Ensures timely and accurate UR responses and reports for daily Flash meeting
• Communicates to relevant parties at the facility, Utilization Review leaders and the Revenue Cycle Team (RCM) any issues with coverage or denials, billing issues and facilitates client notifications as needed
• Attends and participates in Treatment Team Meetings as the payer expert to ensure appropriate authorization outcomes and provides ongoing education regarding payer requirements
• Other tasks and duties as assigned

 Job Qualifications and Requirements

Education:

• Master’s Degree required; Current licensure preferred

 Experience:

• 3 years of Utilization Review experience 
• 2 years of working in a behavioral health setting

 Knowledge, Skills, and Abilities:

• Knowledge of screening practices and basic principles, practices and techniques of drug and alcohol intervention.
• Knowledge of payor medical necessity guidelines, the DSM-5, and ASAM.
• Ability to analyze medical records documentation and apply criteria and guidelines.
• Ability to communicate effectively, both orally and in writing; read and interpret written information; write clearly and informatively; edit work for spelling and grammar.
• Ability to speak clearly and persuasively in positive or negative situations; listen and get clarification; responds well to questions.
• Knowledge of organization, communication, and interpersonal skills.
• Ability to exercise judgment, to interpret results and communicate appropriate course of action.
• Ability to work independently, exercise sound judgment, be attentive to detail, and maintain a positive attitude.
• Ability to maintain confidentiality of all medical, financial, and legal information.
• Ability to complete work assignments accurately and in a timely manner. 
• Proficient in Microsoft Office.