Utilization Review Specialist

JOB SUMMARY

As Utilization Review Specialists, we are the liaisons between insurance payors and the treatment facilities we service, advocating for clients to secure the maximum number of authorized days for them to complete treatment successfully. Utilization Review Specialists are proficient in communication, organization, data entry, multi-tasking, and advocacy.

JOB TASKS AND RESPONSIBILITIES

Insurance Liaison and Authorization

• Serve as liaison between client/facility and their respective insurance carrier.

• Manage caseloads through initial analysis, concurrent review, collaboration, and consultation to obtain maximum reimbursement.

• Establish patients’ current insurance information.

• Communicate with VOB team to ensure up-to-date verification of benefits for every case.

• Assist admission by participation in the pre-certification process.

• Collect and provide initial and concurrent reviews of patients’ clinical status for insurance companies based on initial and continued stay care criteria.

Clinical Collaboration and Advocacy

• Intervene concurrently on behalf of the patient by notifying the attending physician, provider, therapist, and Admissions Director of recommendations for continued treatment based on medical necessity.

• Collaborate with the treatment team to determine the best way to obtain the maximum number of treatment days for each client.

• Assist the treatment team with discharge planning, referrals, and patient care/crisis intervention.

• Stay up to date with clients’ charts to relay accurate information to insurance carriers.

Documentation and Compliance

• Collect and submit data to objectively identify patterns of intervention resulting in desired patient outcomes.

• Complete all insurance and review documentation in a timely manner.

• Facilitate all insurance reviews with respective UR department on time.

• Observe confidentiality of patient information and HIPAA regulations.

Professional Development

• Attend assigned and/or mandatory in-services and staff meetings.

• Participate in professional, continuing education related to the field and keep a record of attendance.

• Identify performance improvement opportunities and participate in quality improvement endeavors.

SKILL SET

Required Skills and Competencies

• Working knowledge of insurance companies and policies.

• Working knowledge of treatment center operations and medical necessity criteria.

• Computer competence (Microsoft Word, Excel, Internet).

• Ability to effectively and professionally communicate with staff and clients.

• EMR experience with any of the following: Kipu, Best Notes, Alleva, Medical Mime, or others.

• Ability to maintain HIPAA compliance.

QUALIFICATIONS

Required

• 2+ years of experience in the behavioral health field.

Preferred

• Clinical license (LMFT, LCDC, LiCSW) or nursing degree (MSN, RN, LVN), or 2 years of experience in a previous UR position.

• 2 years of sobriety if personally represented as “recovering.”

BENEFITS

• 100% remote first company to foster flexibility, inclusivity, and autonomy.

• Competitive salary and performance-based increases.

• Comprehensive health insurance plans.

• Retirement savings plan (401(k)) with employer matching.

• Responsible PTO and holidays.

• Professional development opportunities.

• Collaborative and supportive work environment.

• Recognized as a Great Place to Work by our employees.