Utilization Review Specialist

Summary

The Utilization Review Specialists works on behalf of Behavioral Health facilities assessing patient care plans ensuring its appropriateness to ascertain cost effective treatments, acting as a contact between the facility/provider and insurance carriers.

Responsibilities

• • Reviewing Medical Necessity
• • Authorizations and Approvals
• • Level of Care Determination
• • Concurrent and Retrospective Reviews
• • Communication and Collaboration
• • Appeals Management
• • Data Analysis and Reporting
• • Compliance

Required Skills

• • Clinical Knowledge - having a strong understanding of medical terminology, clinical procedures and healthcare practices.
• • Excellent verbal and written communication skills for interactions with nurses, physicians, insurance representatives etc.
• • Analytical (ability to interpret data and identify trends), Organizational, Computer and Problem Solving Skills.
• • Knowledge of the USA Healthcare Regulations such as HIPPA, Medicare, Medicaid, ASAM Levels.
• • One to three years of experience in utilization review, case management or related field within the Behavioral Health Industry.
• • Strong attention to detail and ability to adhere to strict confidential guidelines.
• • Licensed Practical Nurse (LPN ), certification in healthcare administration or equivalent.

Qualifications

• Required:

  • • Bachelor’s/Master’s degree in computer science or Information technology
  • • Strong attention to detail and a commitment to accuracy
  • • Good computer skills, including proficiency with Microsoft Office Suite (Word, Excel, Outlook)
  • • Effective verbal and written communication skills

• Preferred:

  • • Experience in a file or document processing role
  • • Familiarity with document management systems or software
  • • Ability to work collaboratively in a team-oriented environment

Additional Information and Instructions

If you meet the qualifications and are ready to take the next step in your career, apply today!

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