Takahami Billing is searching for a UR Specialist who is empathic, compassionate, energetic, have strong work ethic, can multi task, who truly care and are passionate addiction professionals. We are currently beginning the talent search and vetting process. Must be very organized and an incredible multi-tasker. We are an EOE and DFWP

Utilization Review Specialist M-F some weekends as needed.

Reports to: Director of Utilization Review

Position Purpose: To ensure that patients receive the appropriate level of care by reviewing and assessing the clinical appropriateness and medical necessity of treatments and services provided to patients with mental health and/or substance abuse issues.

Key Responsibilities:

Clinical Review: Review clinical information and supporting documentation to determine the medical necessity and appropriateness of proposed treatments, admissions, and services.

Collaboration: Work closely with therapists, counselors, doctors, and other healthcare professionals to ensure that patients are receiving the most effective and appropriate care.

Documentation: Maintain thorough and detailed records of all reviews conducted, decisions made, and communications with relevant parties.

Stay Updated: Continually update knowledge on clinical guidelines, evidence-based practices, and criteria pertinent to mental health and substance abuse care.

Case Management: Collaborate with case managers to ensure a seamless patient care experience and to assist with treatment and discharge planning.

Communication: Communicate review outcomes, decisions, and feedback to healthcare providers, insurance companies, and other relevant stakeholders.

Auditing: Conduct internal audits to ensure adherence to organizational policies and procedures as well as regulatory compliance.

Continuous Improvement: Recommend process improvements and policy changes based on review findings, trends, and insights.

Training: Provide training and education to clinical staff on utilization review processes, criteria, and best practices.

Stakeholder Engagement: Develop and maintain positive relationships with insurance providers, healthcare teams, and other stakeholders to ensure smooth and effective processes.

Reporting: Continually update UR reporting via Excel to include authorized days, denied days, used and unused days by facility for each level of care. Tracking of peer reviews and any other pertinent tracking measures assigned.

Qualifications:

A Bachelor’s or Master’s degree in a related field (e.g., Nursing, Social Work, Counseling, Psychology) or previous UR experience, 1 years.

Prior experience in utilization review, case management, or a similar role, preferably in the substance abuse and mental health sector.

Strong understanding of medical terminology, treatment modalities, and clinical criteria such as the American Society of Addiction Medicine (ASAM) criteria or other relevant guidelines.

Excellent communication, analytical, and decision-making skills.

Familiarity with electronic health record systems and other relevant software such as KIPU, Excel, Word, portals, etc.

Preferred:

Certification in Utilization Review, CAP, IADC, or similar.

Experience with insurance and reimbursement processes.

Knowledge of local, state, and federal regulations pertaining to mental health and substance abuse treatment.

Job Type: Full-time

Pay: $55,000.00 - $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday
• Weekends as needed

Work Location: In person