Utilization Review Specialist

Description

Job Summary: The Utilization Review Specialist is responsible for the evaluation of clinical record to determine the appropriateness and necessity of continued stay, type of treatment, and length of treatment.

Responsibilities and Duties:

• Analyzes clinical record and works with the treatment team to collect the required data for communicating with insurance companies to obtain authorization for ongoing treatment.
• Performs concurrent reviews using pre-established criteria ensuring information is accurately communicated to insurance companies.
• Advocates for the patient’s recommended level of care and length of stay.
• Conducts retroactive authorizations and appeals for patients that have lost coverage or switched insurance.
• Works with insurance companies to resolve any authorization related issues.
• Communicates issues with authorizations to treatment team.
• Scans and uploads insurance authorization documents into patients’ record.
• Collaborates with the treatment team to discuss authorization and quality of care.
• Maintains communication with the treatment team to facilitate timely discharge planning.
• Communicates to weekend treatment teams any unauthorized cases ineligible for step down due to pending authorization.
• Initiates level of care step down reviews with commercial and public insurances.
• Closes authorized cases with insurances by submitting discharge clinical.
• Submits necessary documentation to insurance companies for state mandated insurance policies (ACT 106 and NJ Chapter 28).
• Documents all approvals, denials, and discharges in the EMR.
• Collaborates with treatment team to coordinate peer to peer reviews. 
• Tracks and manages authorizations for Bensalem PHP and FRAT IOP via spreadsheet and provides a daily report to outpatient site for visibility on authorized cases.
• Analyzes and reports detox length of stay and discharge status monthly.
• Completes daily counseling census reports which includes client authorizations and distributes to the treatment team.
• Runs weekly reports to ensure patients are imported, fully discharged, or admitted in a level of care for accurate census reporting.
• Demonstrates adherence with ASAM criteria.
• Provides up to date training on ASAM criteria to Livengrin counseling staff from the perspective of the managed care organizations. 
• Establishes an understanding of the use of PAWITS and Red Cap for clients funded by Bucks County.
• Protects the confidentiality of patient information.
• Participates in supervision, department meetings and trainings as required.
• Performs other related duties as assigned.

Qualifications

• Bachelor's degree or licensed nurse preferred.
• Experience in utilization review.
• Experience working in an addiction or behavioral health treatment setting preferred.