Utilization Review Specialist

Position Summary:

Responsible completion of assigned tasks related to preadmission reviews, continued stay reviews, medical necessity requests, and chart audit requests. Supports the organization’s commitment to the principle that providing the most appropriate services, in the least restrictive environment, utilizing proven clinical interventions will lead to the provision of safe and effective care, treatment, or services to meet the individual’s treatment and recovery needs.

Position Responsibilities:

• Completes Preadmission Assessment and/or admission assessment to obtain necessary treatment authorizations. 
• Works with call center and admission staff to obtain, review, assess, and clarify any data, assessment, and/or information that helps develop a full and clear picture of the client’s issues, problems, challenges, mental status, and medical status that will indicate the appropriate level of care required to treat his/her presenting condition safely and effectively.
• Completes Concurrent Reviews as required by payor sources, case management company or other intermediary entity to ensure ongoing communication and preauthorization of services.   This level of review will occur as needed throughout the client’s treatment.
• Arranges for Peer Reviews as requested will coordinate both internal and external peer review process as needed or requested to ensure proper care, treatment, or services.  These services may occur at any time during the client’s treatment.
• Coordinate's provision of Letters of Medical Necessity as needed under the following circumstances:
  • Requested by, or to respond to, insurance company
  • Requested by the billing company
  • Identified as important to support billing and/or UR process.

• Screens all intake files for documented discharge plan to communicate information to insurance provider as needed.  Stays informed of discharge planning issues and changes.
• Will be available to clinical team, medical team, referral sources, and others as needed to provide guidance and consultation regarding placement criteria, level of care, appropriateness of services, coordination of care, and discharge planning.
• Knowledge of Medical Necessity Criteria including ASAM, and other protocols utilized by payor sources.
• Knowledgeable of Levels of Care Criteria as defined by the level of medical and clinical supervision or direct care required of that setting.  Levels of care offered by the facility include Residential Detox and Residential Treatment.
• Coordinates Physician Reviewer or Peer Review calls as needed to perform MD to MD calls as needed.
• Participates in Utilization Review Committee or other committees as needed to present trends and issues.
• Develops, tracks, and manages Dashboard Reports as needed to track and trend key performance indicators.
• Works well with insurance companies, payors, benefits management, case management and other sources to ensure a collaborative relationship.
• Strong knowledge of medical terminology and medical record documentation.  General understanding of laboratory results, frequently used medications, and other basic medical issues.
• Manages discharge dates under the supervision of the manager. Works with operations managers at each facility to assist in smooth transitions for patients.
• Aids the UR Manager in assigning precertification to UR Coordinators and UR Associates.
• Trains new hires in the UR department and evaluates their performance during probationary period.

• Demonstrates competence in one or more of the following areas:
  • Establishing rapport, systematically gathering assessment data, evaluating readiness for treatment and change, and applying accepted diagnostic criteria for substance use disorders.
  • Screening for psychoactive substance toxicity, intoxication, and withdrawal symptoms.
  • Screening for co-occurring mental health conditions.
• Supports the organization’s efforts to comply with National Patient Safety Goals related to:
  • Infection prevention
  • Suicide risk assessment
  • Patient identification
  • Medication reconciliation
• Performs additional responsibilities as assigned by leadership.

Workplace Behaviors

• Demonstrates the ability to complete daily tasks as assigned and meet required deadlines.
• Complies consistently with attendance and punctuality standards.
• Safeguards client rights to privacy and confidentiality at all times.
• Preserves the personal dignity and respect of all clients.
• Maintains a positive, professional, and supportive attitude in the workplace.
• Provides leadership by coaching, supporting, and motivating staff.

Workplace Responsibility

• Seeks supervision, guidance, or direction when necessary.
• Demonstrates initiative in carrying out assigned responsibilities.
• Actively participates in committees and organizational activities as assigned.

Adaptability

• Demonstrates the ability to work objectively and maturely under stress.
• Performs in other capacities as needed to support operational needs.
• Responds positively and professionally to changing workplace situations.
• Actively participates in coaching and makes appropriate corrections to work processes.
• Participates in emergency management and response processes as required.

Professionalism

• Performs duties in a professional manner and consistently conveys a positive image of the mental health profession.
• Works effectively as a collaborative member of the team.
• Complies with organizational dress code and professional appearance standards.

Ongoing Training & Development

• Attends all required in-service trainings and educational courses.
• Assumes responsibility for individual professional growth.
• Contributes to the professional development of colleagues.

Communication

• Seeks and responds constructively to feedback and supervision.
• Develops, interprets, and communicates required policies and procedures appropriately.
• Recognizes and takes appropriate action regarding violations of facility policies and procedures, especially those impacting safety.
• Actively participates as a member of assigned organizational teams.
• Participates in facility performance improvement activities.
• Establishes appropriate rapport with coworkers, clients, and visitors.
• Clearly communicates job-related concerns to supervisors and during staff meetings.
• Consistently reports critical information to supervisors, particularly regarding client care, equipment issues, and supply needs.
• Seeks guidance from appropriate leadership when facility-related issues arise.
• Reports all incidents promptly and completes accurate incident documentation.

Safety, Risk Management, Infection Control & Regulatory Compliance

• Reports any personal symptoms of suspected illness or contagious disease to a supervisor in a timely manner.
• Consistently utilizes proper hand hygiene and infection prevention techniques.
• Reports all incidents and near-misses in accordance with organizational policies and procedures.
• Adheres to all facility policies, procedures, and safety protocols.
• Maintains a safe, clean, and secure physical environment at all times.
• Ensures appropriate protection of client confidentiality in accordance with HIPAA and organizational standards.
• Complies with all Joint Commission Standards applicable to the role.
• Complies with all State Licensing and Regulatory Guidelines.
• Actively participates in Performance Improvement (PI) and Quality Assurance (QA) activities.

Substance Abuse Competency

• Staff who assess, plan services for, and provide care to individuals with substance use disorders demonstrate the knowledge and skills to:
• Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for substance use disorders.
• Screen for psychoactive substance toxicity, intoxication, and withdrawal symptoms.
• Screen for danger to self or others.
• Screen for co-occurring mental health conditions.
• Analyze and interpret assessment data to determine treatment recommendations and clinical priorities.
• Collaborate with the individual served to formulate mutually agreed-upon, measurable treatment goals and objectives.
• Demonstrate adherence to accepted ethical, professional, and behavioral standards of conduct.
• Participate in continuing professional development and ongoing competency training.

Mental Health Competency

• Staff who assess, plan services for, and deliver care to individuals with mental health conditions demonstrate the knowledge and skills to:
• Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for mental disorders.
• Screen for common symptoms of mental illness and psychiatric instability.
• Demonstrate working knowledge of general DSM terminology and diagnostic language.
• Demonstrate understanding of common mental health risk factors.
• Screen for suicidality, self-harm, and other high-risk behaviors.
• Analyze and interpret assessment data to determine treatment recommendations and clinical priorities.
• Collaborate with the individual served to develop mutually agreed-upon, measurable treatment goals and objectives.
• Demonstrate adherence to accepted ethical, clinical, and professional standards of conduct.
• Participate in ongoing continuing education and professional development activities.

Licensures and/or Certifications

• Professional License or Certification relevant to Degree. 

Education and Experience:

• High School Diploma or equivalent required.
• Associate or Bachelor’s Degree in healthcare related studies preferred.
• Minimum of 2 years of experience in utilization review services in substance abuse treatment, behavioral health care, or health care.

Requirements: