Utilization Review Specialist

Position Overview: The primary purpose of the Utilization Review Specialist is to create and manage the flow of revenue for each client through liaison with insurance companies. The Utilization Review Specialist establishes a file on all incoming clients with insurance and maintains authorization for reimbursement from pre-certification through continuing stay reviews through discharge or referral. The Utilization Review Specialist uses communication, reading and writing skills to establish the best, most accurate position of need for each client to ensure maximum reimbursement for care and appropriate reimbursement for the level of care being provided. The Utilization Review Specialist has skills in gathering information from clinicians, navigating EMRs, and creating cases for presentation.

Specific Responsibilities:

· Gather all information salient to insurance reimbursement.

· Call insurance companies to obtain precertification or concurrent certification concurrent with the level of care

· · Establish positive relationships with insurance providers.

· Identify trends in reimbursements and report out to supervisor through verbal report and generation of graphics.

· Work closely with all departments

· Keep accurate records of all transaction and communication with insurances.

· Accurately transfer all information to the Billing Department

· Provides corrective criticism and peer review.

· Reported to work as assigned and keep workplace professional.

· Maintain acceptable overall attendance.

· Promote a favorable/positive work atmosphere.

· Maintains safety of the physical environment.

· Communicate effectively both orally and in writing.

· Independently solve problems and follow through.

· Organize and function independently in an office environment.

· Other duties as assigned.

Minimum Qualifications

· High School Graduate or equivalent. Post high school training in the medical field, the insurance field or in the behavioral health field preferred

· A minimum of two years in the field of medicine, chemical dependency/substance abuse/psychiatric setting or human services field. Experience in third party reimbursements.

· Licensure in nursing, social services helpful but not required.

· Ability to work as a team member and have management, communication, organizational and interpersonal skills.

· Ability to work under stressful conditions and be flexible in relation to department needs.

· Understanding of medical and behavioral health terminology

· Demonstrates Proficiency in Verbal and Written Communication Skills.

· Knowledge of State and Federal Statutes Regarding Patient Confidentiality Laws.

· Knowledge of Drug-Free Workplace Policies.

· Knowledge of Corporate Integrity and Compliance Program.

· Knowledge of current utilized technology.

· Understanding of Insurance policy coverage limits.

· Proficient in Microsoft Office

· Satisfactory CORI and background check.

· Satisfactory drug screen