Utilization Specialist- OMY

Utilization Reviewer Specialist

The Utilization Reviewer Specialist plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position blends strong relationship-building skills with clinical expertise to navigate complex payer requirements, streamline the authorization process, and support members' and participants' transitions.

This role drives the authorization process by reviewing prospective, retrospective, and concurrent Psychiatric Rehabilitation documents to secure prior authorizations by partnering with the relevant managed care team to complete concurrent review authorizations. Acting as a navigator and liaison between the OMY program and the managed care team, the Specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders.

Essential & CORE Functions:

• Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, day authorized, and authorization numbers.
• Coordinates reviews, appeals, and maintains denial logs.
• Consults with appropriate treatment team members for clarification of documentation as needed.
• Assist in identifying patterns of mis-utilization.
• Participates in continuing education to reach professional growth objectives, including maintenance of credentials, certifications, and attending case conferences for clinical/psychiatric rehabilitation updates.
• Maintains and communicates authorization information to all team members.
• Monitor charts {medical records in database) for high-quality documentation when needed on a regular basis, regardless of reviews required.
• Educates new staff members about Medical Necessity/Psychiatric Rehabilitation Necessity criteria, high-quality documentation, and insurance needs.
• Develops relationships and rapport with payers and third-party insurance reviewers.
• Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Consideration grids.
• Coordinates and facilitates pre-admission Prior Authorizations for participants from referral sources.
• Coordinates scheduling with Intake services for transitions in services and/or to other levels of care.
• Cross trains with Psychiatric Rehabilitation Intake Specialist for continuity of care and services delivery.

Additional Responsibilities:

• Performs other duties and special projects as assigned.

Prerequisites & Qualifications for the position:

To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. This position requires individuals who are participant-focused and team-oriented, have strong interpersonal and communication skills, are flexible in the face of sudden changes in workload, emergencies, or staffing, are dependable, have strong problem-solving skills, and are focused on compliance and performance quality. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Education and/or Experience:

Bachelor's degree in human services or care management field. Two years' work in mental health or social services area

Previous utilization experience preferred with managed care organization systems Familiarity with EHR systems

Applicants should have knowledge of Psychiatric Rehabilitation regulations, knowledge of ASAM criteria, and medical necessity criteria.

COMPETENCIES & PERSONAL CHARACTERISTICS:

1. Must have excellent oral and written communication skills, as well as be detail-oriented and able to complete a high volume of documentation in a fast-paced environment.

2. Strong computer skills are required, as well as internet research abilities.

3. Ability to work independently and as part of a team.

4. Knowledge of mental health system and support.

5. Must be available for local travel.

6. Participation in on call coverage as applicable.

7. May be required to report to work during emergencies including inclement weather.

ORGANIZATIONAL ACCOUNTABILITY & RELATIONSHIPS:

1. The individual is to be supervised by the Director.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds.

Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT:

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time. The noise level in the work environment is usually moderate.

GENERAL SIGN OFF:

The employee is expected to adhere to all agency policies and to act as a role model in adherence to agency policies.