Utilization Review Specialist
First Step
General Description
The Utilization Review Specialist processes all insurance authorizations for partial hospitalization programs, intensive outpatient programs and outpatient programs across business entities to ensure timely and appropriate services for clientele. Tasks & Responsibilities A. Essential Duties
The Utilization Review Specialist processes all insurance authorizations for partial hospitalization programs, intensive outpatient programs and outpatient programs across business entities to ensure timely and appropriate services for clientele. Tasks & Responsibilities A. Essential Duties
- Handle the continuum of the utilization process for all ABHS entities.
- Outreach to insurance companies to gain authorizations for services such as TMS, partial hospitalization, intensive outpatient and outpatient programming.
- Maintain ongoing communication with the Patient Access Center, Billing Department, Clinical Department and Medical Department.
- Evaluate and assure adequacy of clinical information to screen for medical necessity
- Consultation with internal Clinical and Medical staff regarding alternate services and clinical criteria
- Administer appeal process for denials
- Assists and covers other staff when necessary to maintain high productivity and efficiency in the department.
- As the company continues to grow, additional responsibilities that are essential for the department to be successful will be assigned accordingly.
- Create Meaningful Connections: Demonstrates ability to function effectively as a part of team. Uses outstanding oral and written communication with employees at all levels of the business for support and sharing of information.
- Take Accountability: Take constructive feedback and prevent discourse among our peers.
- Live in the Solution: Critically thinking should be the solution when problems arise. Having the ability to accept constructive criticism well in an open and non-defensive manner.
- Be Professional: Wear business casual attire (please see dress code policy).
- Adaptability
- Customer Service
- Decision Making
- Dependability
- Ethics
- Interpersonal Skills
- Job Knowledge
- Conflict Management
- Organization Skills
- Productivity
- Self-Development
- Teamwork
- Compliance with essential and incidental duties; compliance with company policies and procedures.
- Compliance with state and federal laws and regulations applicable to the business.
- Use of computer, telephone, and other office equipment such as a printer and fax.
- Use of company network and email domain.
- Air conditioned and well-illuminated office environment and outdoor environment.
- May have several responsibilities at once. Interaction with others is constant and can be interruptive.
- Work may be stressful at times due to high level workflow.
- Availability to work flexible hours including weekends, holidays, and evenings as is required to comply with the purpose of the job and accommodate client needs.
- Participates in educational training, orientations, or compliance programs as needed to maintain competency.
- If you must leave your employment with our company, we request employees to give us at least 14 days resignation notice in writing.
- Enthusiastic self-starter operating with sustained energy and showing great initiative.
- Comfort working with a diverse base of support, including members, employers, providers, colleagues, community leaders, volunteers, non-profit organizations, vendors, etc.
- Excellent interpersonal and communication skills, including ability to read, write, spell in English legibly and without excessive grammatical or communication errors.
- Talk and hear both by person and by telephone; ability to speak clearly and effectively using proper grammar before patients, employees and business partners, among others.
- Excellent organizational skills.
- Accepts constructive criticism well in an open and non-defensive manner.
- Ability to manage conflicting priorities. Ability to maintain a positive work ethic and a congenial attitude in the face of a high-pressure environment.
- Ability to function independently and with flexibility.
- Ability to work under pressure, handle multiple tasks and interruptions.
- Occasional lifting of moderately heavy office supplies; ability to lift supplies for community events, trade shows, conferences, and other marketing opportunities applicable to the organization; ability to lift, push or pull up to 25lbs.
- Ability to sit, stand, or walk for extended periods of time.
- Excellent presentation, negotiation and relationship-building skills required.
- Must have strong computer skills to meet Microsoft Office and Electronic Health Record software requirements.
- High School Diploma or equivalent education required
- At least 1 year of Utilization Review experience
- Experience working in an electronic medical records system.
- Computer literate: Microsoft Office (Excel, Word, and PowerPoint) required.
Vacancy posted 3 days ago
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