Utilization Review Specialist
Under the direction of the Utilization Review Director (URD), the Utilization Specialist acts as a liaison with a patient’s insurance company, coordinates billing, payments, authorizations with insurance companies, and monitors authorizations.
High School Diploma/Equivalent
Current CPR Certification
Valid Driver’s License
Proficiency in Microsoft Office Suite, including Word, Excel
5 years’ working experience or a minimum of Bachelor’s Degree in Social Work/ Psychology or other related field
1 year experience working in a residential/behavioral healthcare setting.
Experience working with insurance companies.
Master’s level degree and licensure in social work.
JOB DUTIES AND RESPONSIBILITIES
Act as an advocate and liaison with client’s insurance to coordinate authorization for treatment.
Managing patient authorizations for treatment.
Coordinate with clients, treatment team members and billing department routinely to ensure timely and necessary communications to obtain authorizations and claims payment from payers.
Complete initial pre-cert requests with new admits as well as manage ongoing concurrent reviews for continued authorizations from payers.
Auditing and submitting requested medical records for claims
Maintain all spreadsheets and data sources to track authorizations and data.
Maintain organization and filing of all patient financial records.
All other duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES
Ability to communicate effectively both verbally and in writing.
Computer literacy and proficiency in the use of Microsoft Office software.
Knowledge of medical and behavioral health terminology
Knowledge in reviewing medical and behavioral health records for medical necessity
Skill in operating a personal computer and utilizing a variety of software applications, printer and fax machine.
Ability to apply UR Guidelines and processes consistently
Knowledge of the current version of the Diagnostic Statistical Manual of Mental Disorders (DSM)
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