SUMMARY: The Utilization Review Specialist at Moriah Behavioral Health is responsible for using their clinical knowledge and/or nursing experience to complete preauthorization and concurrent review requests for all levels of care. Must collaborate with clinical and admissions staff to gather necessary information for thorough preauthorizations and concurrent reviews. Stay updated on relevant laws, regulations, and policies. Participates in treatment team meetings, reviews client charts, and completes requests for Single Case Agreements (SCA’s) or Letters of Agreement (LOA’s) with out-of-network insurance providers. Write appeals, carry a caseload, and communicate inter-departmentally regarding insurance denials. The role requires an advanced understanding of clinical terminology, the ability to build rapport and a strong grasp of medical necessity criteria.
DUTIES AND RESPONSIBILITIES:
? Using clinical knowledge and/or nursing experience, the Utilization Review Specialist reviews requests for preauthorization and concurrent reviews for all levels of care offered, and works closely with clinical staff and admissions staff to collect all information necessary to perform a thorough medical necessity review.
? Completes Peer reviews as necessary and/or assists in scheduling Peer reviews and Live Appeals with the appropriate person.
? Attends treatment team meetings as assigned (virtually), and communicates extensively with the treatment team concerning client progress.
? Reviews client charts for updated clinical information, notifies clinician, clinical director, and clinical documentation specialist if clinical data is not up to date. Notifies Utilization Review Director and/or Supervisor if clinical data is not up to date.
? Initiates Prior Authorizations, and works closely with Admissions staff during the process. ? Completes requests and provides rationale for Single Case Agreements (SCA’s) or Letters of Agreement (LOA’s) with out of network insurance providers.
? Writes appeals under the supervision of the UR Supervisor or greater. ? Carries a utilization review caseload as appropriate to departmental needs. ? Communicates with Supervisor or greater, Billing, and Clinical teams regarding insurance denials.
? Communicates with Billing for Verification of Benefits (VOB’s), change of insurance, etc. ? Audits historical clinical records.
? Responds to medical records requests and follows up to ensure completed appropriately.
QUALIFICATIONS:
? Minimum Associate Degree with clinical experience and/or nursing experience or equivalent combination of education and experience.
? Previous clinical documentation experience in healthcare-related fields. ? Computer Skills Required. Preferred (but not required) Kipu, Excel, Salesforce, Google Docs, etc.
? Must possess the ability to function effectively in a team environment and interact productively with all levels of team personnel and outside contractors.
? Applicant must be either a U.S. Citizen or have the legal right to work in the United States.
? Must meet federal, state, and local Criminal Clearance and Child Abuse Indexing requirements.
? Applicants must pass a drug screen and submit to random drug tests as requested. ? Applicants are also required to pass a general medical evaluation.