Utilization Review Coordinator

Pinnacle Peak Recovery, LLC is a Scottsdale-based Detox, Residential, and PHP / IOP extended care treatment facility treating adult men and women recovering from the effects of substance dependence.

At PPR, our goal is to assist our clients in regaining the life they were intended to have, prior to drug / alcohol addiction.

We work together as a multi-disciplinary team, to treat each client individually with the highest level of clinical and medical interventions available.

Our staff are dedicated, skilled, and passionate about working with recovering men and women. If you are passionate about working in the field of recovery, we'd love to meet you!

The Utilization Review Coordinator is an analytical, detail-oriented and organized professional responsible for all Utilization Review functions.

The UR Coordinator is responsible for, but not limited to pre-certification, and initial and concurrent reviews for client’s treatment.

This position works as part of the billing team and closely with the clinical and medical teams to act as a liaison between Pinnacle Peak Recovery and the insurance organizations.

Duties and Responsibilities :

• Reviews benefit verification with insurance organizations for covered services and precertification requirements.
• Inputs reviews into the Utilization Review calendar to ensure timely scheduling of reviews.
• Gather and analyze all information in client chart.
• Ability to review client records in depth and work with treatment team to gather required medical and clinical information to support client's admission and continued stay.
• Working knowledge of DSM IV Axis I-V, DSM V, ICD-10 and ASAM criteria.
• Broad understanding of dual-diagnosis issues and treatment protocols.
• Assess and distinguish levels of care for clients based on clinical and medical assessments and information using ASAM criteria.
• Coordinates obtaining signed releases of information for the patient to facilitate timely communication of clinical and medical information.
• Complete initial and concurrent reviews with insurance organizations as scheduled to ensure client level of care authorization and length of stay.
• On an ongoing basis, identify potential review problems and discuss them with supervisor and applicable departments.
• Coordinates peer to peer and / or doctor to doctor reviews with insurance organizations and medical and / or clinical treatment team.
• Document contact and outcomes of reviews with insurance organizations as indicated in a timely manner.
• Completes retro authorization appeals as needed.
• Creates, maintains, and tracks various utilization review reports.
• Able to interact with diverse client population.
• Assists with completing various client assessments.
• Assists with various chart audits and reports.
• Occasionally assists with insurance Verification of Benefits.
• Participate in department in-service / training programs and various staff meetings.
• Attend continuing education classes to maintain license and / or certification, if applicable.
• Complete special assignments and responsibilities as requested by supervisor.
• Performs other duties as assigned.

Skills and Abilities :

• Strong communication, including writing, speaking and active listening.
• Strong problem-solving and critical thinking skills.
• In-depth knowledge of insurance and best practices.
• Must be detail oriented and familiar with databases and extrapolating data.
• Strong interpersonal, organization, analytical, time management and prioritization abilities.
• Strong teamwork and organizational awareness.
• Excellent judgment and initiative.
• Functions as a core member of the health care team.
• Regularly communicate with other team members and interface in a positive, constructive, and helpful manner to promote collaboration, cohesiveness, reduce conflict, and provide for resolution.
• Able to work under pressure and meet deadlines as well as be flexible and dependable.
• Demonstrate the ability to understand and react effectively to the unique needs of the clients and team.
• Strong writing skills and understanding of clinical and medical terminology.
• Understanding of CPT, HCPCS, Revenue Codes, and insurance procedure guidelines.
• Strong understanding of DSM IV Axis I-V, DSM V, ICD-10 and ASAM criteria.
• Knowledge of Joint Commission standards.
• Strong knowledge and compliance of HIPAA, ethic, and legal protocols.
• Basic math and strong computer skills (Billing systems, Email, Microsoft Office Word, Excel, Teams, etc.)
• Ability to use standard office equipment such as copier, fax machine and other equipment as required.
30+ days ago