Utilization Review Specialist

Job Description

Job Description

Company : Skyway Behavioral Health

Title : Utilization Review Specialist (URS)

FLSA Status : Exempt

Location : Remote

Skyway Behavioral Health is an innovative center that goes beyond the treatment of mood, anxiety, and eating disorders to address underlying traumatic stress. Our belief is that maladaptive coping strategies are adopted by patients for survival. While adaptive at one time or in specific ways, these coping strategies are now preventing patients from living the life they want to live and have evolved into psychiatric symptoms and disorders.

At Skyway, we provide a fully immersive, intensive, whole-person experience that covers everything from neuroscience to nutrition. We believe that the path to recovery requires a focus that encompasses not just symptom management but also the treatment of underlying individual, systemic, developmental, and familial trauma. We use cutting-edge, specialized, evidence-based treatment modalities to help our patients address the trauma and pain behind their behaviors and diagnoses – thereby empowering them to make lasting changes in their lives.

Our team has extensive clinical and leadership experience in the areas of traumatic stress, eating disorders, mood disorders, and personality disorders / pathology. At Skyway, we are committed to building a culture and team that cares for one another such that we may care for our families, communities, and clients. At Skyway, we believe that recovery is not only possible but also attainable for all patients.

Role Description

Utilization Review Specialist (URS) reports to the Utilization Review Manager and serves as the primary advocate for Skyway patients to attain insurance coverage for clinically necessary treatment to improve quality of life and wellbeing. Skyway views the URS as an integral role to the treatment process, the URS establishes and maintains the necessary conditions for financial reimbursement and navigates communications with insurance providers. A critical element of the Skyway mission is to ensure that all team members, even those not providing direct clinical care, know and believe they can change and improve patient’s lives; and when serving with integrity and in alignment with the Skyway Mission, we create a reverberating positive impact on the patients.

Essential Functions / Core Responsibilities

• Completes pre-authorizations, concurrent reviews, and internal UR reviews.
• Consults with necessary members of the multidisciplinary treatment team to attain required information to complete concurrent reviews.
• Coordinates urgent / expedited appeals and peer to peer reviews, as necessary.
• Serves as a liaison with medical staff to ensure individual cases are reviewed with MDs as needed.
• Follows all standard HIPPA, Joint Commission and Skyway Utilization Review Department policies and procedures.
• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
• Utilizes all UR department reporting tools to ensure department efficiency and effective deployment of role responsibilities.
• Maintain completion of all competencies associated with role and in accordance with Skyway Behavioral Health policies and subsequent Joint Commission standards.
• Makes all initial calls within 24 hours and follow up calls every 24 hours as necessary and during regular schedule business hours.
• Supports the organization's mission, vision, values, and strategic initiatives. Develops, implements, and improves processes to ensure that established policies, goals, and objectives are achieved. Ensures compliance with all applicable local, state, federal regulations, and guidelines.
• Performs other duties as assigned.

Minimum Requirements

Additional Preferred Skills

A passion for coaching, mentorship, and team-development.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit (50%-75%) and talk or hear. The employee frequently is required to stand; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl. The employee is occasionally required to walk and climb or balance, push and or carry supplies up to 30lbs. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Benefits :

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit (50%-75%) and talk or hear. The employee frequently is required to stand; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl. The employee is occasionally required to walk and climb or balance, push and or carry supplies up to 30lbs. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Skyway Behavioral Health is proud to be an Equal Opportunity Employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

We celebrate diversity and are committed to creating an inclusive environment for all employees.