Utilization Review Specialist

Job Description

Job Description

PRN position-Remote

Entry Level Qualifications :

A current RN, LPC, LMFT, LMSW, or LCSW license preferred, but not required. Two years minimum experience in utilization review preferred. Must possess good grammatical and communication skills. Must be skilled in Microsoft Office applications and have a working knowledge of office equipment.

1.Must be able to read and comprehend hand-written, printed, and on-line treatment notes and plans.

2.Must be able to hear and comprehend conversations and instructions.

3.Must be able to continuously sit for approximately 7 hrs. per 8 hr. shift.

4.Must be able to walk within the facility a total of approximately two (2) hrs. per day.

5.If recovering, two years of continuous verifiable abstinence.

General Responsibilities :

Complete coordination of the facilities insurance certification including precertification and continued stay reviews, as well as follow up on all insurance denials, appeals and reconsiderations.

Essential Functions :

1.Perform all pre admission certification reviews, continued stay reviews, appeals, denials and / or reconsiderations and provide information to the appropriate review agency or insurance company.

2.Maintain an "UR Activity Log" which records every review for the facility with financial classification and U.R. information / activity.

3.Maintain a "call back' calendar for continued stay reviews and maintain a U.R. file for each patient.

4.Document, in the patient electronic record software, the review with the managed care organization, including the level of care requested, the status of the request, outcome and information about the next review.

5.Review and maintain all correspondence pertaining to certification, appeals, denials or reconsiderations, and ensure they are scanned into the patient electronic health record.

6.Complete all Quality Improvement indicators for Utilization Management, data analysis and reporting.

7.Educate counseling staff regarding data needed to adequately document patient care and educate crisis staff regarding data needed to adequately document intake assessments and managed care criteria.

8.Ability to work in a constant state of alertness as to perform the job safely.

9.Ability to work in cooperative manner with co-workers, managers, clients and prospective managers.

10.Regular attendance.

11.Any other duties as assigned by supervisor.