Utilization Review Specialist - Behavioral Health

Skyway Behavioral Healthis an innovative center that goes beyond the treatment of mood, anxiety, and eating disorders to address underlying traumatic stress. Our belief is that maladaptive coping strategies are adopted by patients for survival. While adaptive at one time or in specific ways, these coping strategies are now preventing patients from living the life they want to live and have evolved into psychiatric symptoms and disorders. At Skyway, we provide a fully immersive, intensive, whole-person experience that covers everything from neuroscience to nutrition. We believe that the path to recovery requires a focus that encompasses not just symptom management but also the treatment of underlying individual, systemic, developmental, and familial trauma. We use cutting-edge, specialized, evidence-based treatment modalities to help our patients address the trauma and pain behind their behaviors and diagnoses – thereby empowering them to make lasting changes in their lives. Our team has extensive clinical and leadership experience in the areas of traumatic stress, eating disorders, mood disorders, and personality disorders/pathology.At Skyway, we are committed to building a culture and team that cares for one anothersuchthatwemaycareforourfamilies, communities, andclients. At Skyway, we believe that recovery is not only possible but also attainable for all patients. Role Description Utilization Review Specialist (URS) reports to the Utilization Review Manager and serves as the primary advocate for Skyway patients to attain insurance coverage for clinically necessary treatment to improve quality of life and wellbeing. Skyway views the URS as an integral role to the treatment process, the URS establishes and maintains the necessary conditions for financial reimbursement and navigates communications with insurance providers. A critical element of the Skyway mission is to ensure that all team members, even those not providing direct clinical care, know and believe they can change and improve patient’s lives; and when serving with integrity and in alignment with the Skyway Mission, we create a reverberating positive impact on the patients. Essential Functions/Core Responsibilities Completes pre-authorizations, concurrent reviews, and internal UR reviews proficiently and in a timely manner. Effectively verifies the accuracy of diagnostic and service codes by reviewing clinical documentation, ensuring precise alignment between authorized services and documented mental health needs. Demonstrates a high level of accuracy in applying codes to support appropriate level-of-care determinations and compliance standards. Implements a system of organization and time management to ensure completion of all reviews and timely documentation within the EMR. Coordinates urgent/expedited appeals and peer to peer reviews, as necessary. Routinely follows up on pending authorization requests at regular intervals to ensure financial reimbursement. Demonstrates strong interpersonal and communication skills with an interdisciplinary team to attain required clinical information and communicate any feedback from insurance payors. Serves as a liaison between clinical staff and insurance by communicating payer feedback and conceptualizing medical necessity to insurance payers. Consults with necessary members of the multidisciplinary treatment team to attain required information to complete concurrent reviews. Makes all initial calls within 24 hours and follow up calls every 24 hours as necessary and during regular schedule business hours. Demonstrates strong critical thinking and process-oriented skills to effectively navigate the utilization review process, applying a solid understanding of diagnostic criteria to evaluate medical necessity, level of care, and service appropriateness. Ability to support team members by providing any case coverage or additional support as needed. Attend interdisciplinary meetings with clinical team to communicate any insurance concerns or necessary clinical considerations. Follows all standard HIPPA, Joint Commission and Skyway Utilization Review Department policies and procedures. Maintain completion of all competencies associated with role and in accordance with Skyway Behavioral Health policies and subsequent Joint Commission standards. Supports the organization's mission, vision, values, and strategic initiatives. Develops, implements, and improves processes to ensure that established policies, goals, and objectives are achieved. Ensures compliance with all applicable local, state, federal regulations, and guidelines. Performs other duties as assigned. Minimum Requirements Minimum 2 years of experience with utilization review in a health care provider or insurance environment required. Undergraduatecollegedegree or relevant experiencerequired, master’s degree in social work or counseling field preferred. Exceptionalorganization skills, reliable and timely. Excellent interpersonal and communication skills that are clear, respectful, and considerate of other’s perspectives. Strong critical and process-oriented thinking skills to successfully navigate the UR processes. Proficiency in behavioral health UR process, with solid understanding of diagnostic criteria. Ability to effectively communicate Skyway program services, and clinical necessity respective to diagnosis. Ability to work independently with limited supervision. Reliable form of transportation to work. Proficiency in Microsoft products (Word, Outlook, Excel), familiarity with use of EHR systems and insurance provider platforms. Additional Preferred Skills A problem-solving orientation and eagerness to identify process gaps and implement practicalsolutions. While working independently, recognizes the need for support and demonstrates the willingness to ask for help. Ability to manage multiple prioritiesand respond with confidence during challenging or chaoticsituations. Someone who embodiesSkyway values. A passion forcoaching,mentorship, and team-development. Embraces the whole person. Commits to innovative research-based programs. Believes we are better together. Celebrates expressions of diversity. Believes in service and supporting our communities. Views leadership as a privilege to elevate others to their highest potential. 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 accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit (50%-75%) and talk or hear. The employee frequently is required to stand; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl. The employee is occasionally required to walk and climb or balance, push and or carry supplies up to 30lbs. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Benefits: Medical benefits- Blue Cross Blue Shield of Illinois Dental benefits- Blue Cross Blue Shield of Illinois Vision benefits- Blue Cross Blue Shield of Illinois Short & Long Term Disability-Blue Cross Blue Shield of Illinois 401K Safe Harbor Match- Ameritas Blue Star PTO Paid Floating Holidays Paid Wellness/Self-Care Days Holiday pay Paid sick time Collaborative professional growth development Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit (75%-100%) and talk or hear. The employee frequently is required to stand; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl. The employee is occasionally required to walk and climb or balance, push and or carry supplies up to 30lbs. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Skyway BehavioralHealth is proud to be an Equal OpportunityEmployer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are committed to creating an inclusive environment for all employees. #J-18808-Ljbffr Skyway Behavioral Health