UTILIZATION REVIEW SPECIALIST

The Utilization Review Specialist proactively monitors and assesses clinical documentation and medical records to ensure that medical necessity criteria are met for each level of care. The UR Specialist coordinates with the medical and clinical staff to prepare documentations to present to insurance companies for continued authorization. The focus of our UR Specialist is to manage the review and approval process allowing the clients clinical and medical staff time to a focus on providing the highest level of care for their clients.

THE BENEFITS

We know we wouldn't be here if it wasn't for our team, and it's important that they know it too.

We provide an excellent compensation package which includes competitive salary, company sponsored top-notch healthcare, Gap coverage. Company paid Short and Long Term Disability and life insurance policy. Our team members can elect dental, vision, and supplemental insurance benefits.

Essential Functions:

• Performs clinical review for medical necessity for Facility/Member/Provider using evidenced based guidelines, policies, benefits and nationally recognized clinical criteria
• Conducts pre-certification reviews and appeals reviews
• Conducts retrospective clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Negotiate with insurance companies to achieve the highest level of care for patients / clients based upon ASAM and other approved criteria
• Conduct continuous reviews of patient progress advocating for continued client care at the maximum length of care with the highest level of benefits.

Qualifications:

• Proven track record of UR in Behavioral Health and Substance Abuse
• Knowledge of ASAM / DSM V / ICD-9, 10
• Knowledge of Kipu, Sunwave and Collaborate MD preferred.

EOE