UTILIZATION REVIEW SPECIALIST

Job Description

Job Description

JOB DESCRIPTION

Job Title : Utilization Review Specialist

Department : Utilization Review

FLSA Status : Exempt

JOB SUMMARY

The UR Specialist applies expertise of payor behavior and clinical guidelines to optimize utilization review outcomes. The UR Specialist analyzes factors that result in denials to identify opportunities for improvement through collaboration with facility partners.

The UR Specialist also assists revenue cycle with billing, appeals and denial duties.

ESSENTIAL FUNCTIONS

• Prescreens referrals to anticipate authorizations and provides recommendations regarding level of care, services and treatment planning.
• Collaborates with clinical team to prepare and present complex requests to the payor for determination of care and rapid re-admissions.
• Helps train and provide clinical documentation training as needed to clinical / nursing / other teams within Infinite Recovery
• Coordinates and documents all concurrent insurance reviews with clinical and medical team and provides notices for missing documentation.
• Reviews medical records for quality clinical documentation and compliance and provides feedback to licensing, accrediting and payor requirements.
• Conducts live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and / or American Society of Addiction Medicine (ASAM) to compel authorization.
• Negotiates clinical authorization outcomes with the payor, collaborating in advance with primary treating clinician.
• Coordinates, provides guidance and assists with scheduling for Peer to Peer review preparation.
• Establishes internal authorization or denial for No Authorization Required (NAR) requests and establishes post denial appeal response recommendations.
• Ensures timely and accurate UR responses for daily report.
• Coordinates with Admissions and Billing team for expected insurance contribution for continued stay.
• Maintains billing information based on census and communicates to relevant parties at the facility and with any issues with coverage or denials, billing issues and facilities with client notifications as needed.
• Attends and participates in treatment team meetings as the payor expert to ensure appropriate authorization outcomes and provides ongoing education regarding payor requirements.
• Completes Denial Notification process and assists revenue cycle team with explanations to the client or family regarding the denial.
• Managing projects, assisting with UR auditing, and assisting with providing staff training related to UR activities.

The job duties listed in this job description may not be inclusive of all requirements of this position. Other duties may be assigned by your supervisor.

SUPERVISORY RESPONSIBILITIES

This job has no supervisory responsibilities.

QUALIFICATIONS

Two (2) years of utilization review or quality assurance or discharge planning experience. In lieu of degree, a Licensed Chemical Dependency Counselor (LCDC) or Licensed Vocational Nurse (LVN) with a minimum of one (1) year of working experience in utilization review, quality assurance or discharge planning in addition to meeting the qualifications listed below.

Experience working in a psychiatric and / or substance abuse health care environment.

Prior working experience in a drug or alcohol treatment facility.

Strong knowledge with payer requirements for medical necessity reviews for different levels of care.

Strong knowledge of TDI / ASAM medical necessity criteria, and must be able to clearly and effectively communicate this to payers.

COMPUTER SKILLS

To perform this job successfully, an individual should have knowledge of Microsoft Office (Word, Excel, and Outlook), Google Suite, and have the ability to chart on an electronic medical records system.