Full-time Utilization Review Specialist

St. Joseph’s Addiction Treatment and Recovery Centers

Hybrid Location: Remote / Inpatient Facility - Saranac Lake, NY 

Position: Full-time Utilization Review Specialist

Shift/schedule: Monday-Friday / 8:00a-4:30p

Pay Range: $22.00/hr to $28.60/hr

Position Summary: This position will work with clients, admissions, finance, and medical departments, as well as insurance companies to facilitate admission and continued stay in the facility. Utilize knowledge of managed care process including insurance verification and continued pre-certification and concurrent reviews. Utilize knowledge of medical and psychiatric diagnoses, screening tools, and psychiatric medication and be versed in DSM and ICD guidelines and codes. Working knowledge of insurance payments practices. Strong attention to detail, excellent organization skills, and ability to multitask in a fast-paced environment.

Education and Training: Minimum of three to five years of experience in NYS health care. NYS Qualified Health Professional required or actively working to obtain QHP status. Must be computer literate with knowledge of Microsoft applications, bachelor’s degree in behavioral health discipline preferred.

Qualifications and Requirements:
Minimum of three years of behavioral health care experience or five years in the behavioral health field with a concentration in chemical dependency.

Essential Duties:

• Gather data about clients from admissions department and clinicians. Monitor documentation for accuracy and clinical compliance. Provide feedback, as necessary, to appropriate staff regarding finding and reviews.
• Review patient documents for medical necessity.
• Communicate clinical information as required to insurance company reviewers to obtain authorization to treat and for continued stay authorization.
• Facilitate dissemination of information as required by insurance company providers and staff.
• Coordinate reviews with Medical Director as necessary.
• Provide written summaries as required by insurance companies after review with insurance has been conducted.
• When necessary, conduct peer reviews to ensure clear understanding of how to deal with initial denials and to obtain observation for appropriate level of care.
• Manage individual clients across the health care continuum to achieve optimum clinical, financial, operational, and satisfaction outcomes.
• Establish and promote collaborative relationship with physicians, payers, and other members of the health care team. Collect and communicate pertinent, timely information to payers and others to fulfill utilization and regulatory requirements. Maintains strong working relationships with clients and payers and professionally communicates information as needed or required.
• Educate staff on case management and managed care concepts. Facilitate integration of
• concepts into daily practice.
• Participate in the discharge planning process and identify appropriate resources both internal and external required for successful transition of care to an alternative setting.
• Responsible for effective and sufficient support of all behavioral utilization activities according to policies and procedures.
• Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for pre-admission, concurrent review, discharge planning, and follow-up assessment.
• Assure compliance with State, Federal, CARF standards/regulations and SJRC policies and procedures.
• Maintain continued professional education.
• Actively participate in meetings, committees, and quality assurance activities.
• Maintain current NYS license(s) and/or credentials as appropriate.
• Perform other duties as may be assigned by the Inpatient Services Director.