Utilization Review Specialist

The URS is responsible for creating and managing the flow of revenue for each client at Clean Recovery centers through liaison with insurance companies. The URS establishes a file on all incoming clients with insurance and maintains authorization for reimbursement from pre-certification through continuing stay reviews, through discharge of referral. The URS uses communication, reading and writing skills to establish the most appropriate reimbursement for the level of care being provided. The ideal candidate has skills in gathering information from clinicians, navigating EMRs and creating cases for presentation. Maintains internal tracking documents and spreadsheets daily and/or as instructed.

URS is responsible for ensuring the necessity and appropriateness of care effective benefit management and coordination

1. Reviewing medical necessities and medical record documentation and communicating health concerns for obtaining information.
2. Calls insurance companies to obtain precertification or concurrent with the level of care.
3. Attend team meetings to gain information and provide training to clinicians as to data needs.
4. Establish positive relationships with insurance providers.
5. Identify trends in reimbursements and report to supervisor through verbal and generation of graphics.
6. Promptly work on denials of level of care and obtaining necessary additional medical history to overturn denials.
7. Following up and communicating treatment plans to insurance payors for ongoing authorization.
8. Ensuring prompt Communication to management on denials or payor issues.
9. Work closely with all departments.
10. Keep accurate records of all transactions and communication with insurances.
11. Accurately transfer all information to the billing department.
12. Knowledge of Insurance company portals, payspan, zelis and other portals
13. Knowledge of Microsoft Word, Outlook and Excel required
14. Knowledge of Adobe required
15. Reports to work as assigned and keep workplace professional.
16. Maintain acceptable overall attendance.
17. Attends in-service and educational training as necessary and assigned.
18. Reports personal symptoms of suspected illnesses and contagious diseases to supervisor.
19. Reports incidents, accidents, and occurrences in accordance with policy and procedure.
20. Maintains safety of the physical environment.
21. Independently solves problems and follows through.

Perform other duties and tasks as assigned.

High School Diploma or equivalent

Experience with ASAM and LOCUS criteria  

Ability to interpret ASAM, LOCUS InterQual, 12 step and Treatment Planning for SUD and MH and to apply information to patient authorizations 

Ability to work with a team and have effective communication, organizational and interpersonal skills 

Ability to work under stressful conditions and be flexible in relation to department needs 

Understanding of medical and behavioral health terminology 

Knowledge of state and federal statutes regarding patient confidentiality 

Attention to detail

Experience preferred in behavioral health initial and concurrent review processes