Senior Utilization Review Specialist

Senior Utilization Review Specialist

Within Health is revolutionizing eating disorder treatment through our innovative telehealth platform. We provide remote clinical services at the Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) levels of care. Our mission is to transform lives by increasing access to quality eating disorder treatment, improving patient outcomes, and fostering healing in a compassionate, stigma-free environment. We combine clinical expertise with cutting-edge technology to address the complex needs of individuals with eating disorders, creating a future where effective treatment is accessible to all who need it.

The Role

The Senior Utilization Review Specialist (SURS) provides administrative support and management to Within and clients. Additionally, The URS works collaboratively with insurance companies, and clinical staff.

What You'll Do

• Maintain efficient methods for ensuring the medical necessity and appropriateness of prescribed level of care.
• Oversee the entire UR process for client journey from admission to discharge.
• Complete precertification process and associated documentation.
• Audit charts to ensure content reflects medical necessity guidelines.
• Ensure continued stay reviews are completed, accurate, and timely.
• Assist clinical staff with appeals when necessary.
• Provide support to clinical staff around the UR process.
• Train new clinical staff on UR process and procedures including documentation of medical necessity.
• Provide ongoing training for existing staff on UR and documentation.
• Submit initial assessments, continued stay assessments, and payer requested reviews following the established policies and governing regulations to ensure the payer receives notification and documentation that the client meets medical necessity for admission at the correct level of care.
• Communicate with commercial payers per request of payer and Within policy.
• Issue complete and concise communications, submitting the critical elements that establish medical necessity to ensure timely authorization and reduce the potential for denials.
• Follow-up on approval/denial if no reply is received within 12-24 hours by telephone or payer portals.
• Document all actions and activities in the case management and billing management systems, including but not limited to, initial submissions, escalations, avoidable days, payer contacts, authorization numbers, denials, etc. (Documentation must be clear and complete for billing and case review).
• Will advise clinical staff on peer review and/or appeals process and provide oversight when necessary.
• Communicate with Admissions Specialists and other members of the Clinical team to ensure effective collaboration between all disciplines.
• Compiles reports and statistics for presentation to the Utilization Review Committee upon request.
• Other duties assigned by the supervisor.

Qualifications

• Experience in a business or health-related field or an equal combination of education and applicable experience within a higher level of care eating disorders setting.
• Minimum of 1 year experience performing insurance verification, utilization review or intake assessments in a Residential Treatment Center (RTC), Partial Hospitalization Program (PHP) and/or Intensive Outpatient Program (IOP) environment, eating disorders setting preferred.
• Ability to assist in the development and process improvement of obtaining payor authorization and concurrent appeals.
• Manages time effectively, setting priorities, and consistently meeting deadlines.
• Ability to effectively interact with insurance companies.
• Demonstrates initiative and proactive approach to problem resolution.
• Can perform well independently and on a team.
• Assumes accountability for behaviors consistent with the customer service policy.
• Competent in computer based charting, clinical, and non-clinical software programs.
• Understands commercial coverage details.
• Operates office equipment efficiently.
• Demonstrates appropriate judgment and discretion in the UR Coordinator role.

Physical & Environmental Requirements

• Must have reliable internet connection.
• Must be comfortable operating a computer and smart-phone and navigate applications within macOS and iOS.
• Must be comfortable communicating with colleagues via chat, telephone, and video calls.
• Must be able to sit for the majority of the shift.
• This is a work-from-home position. Work should be performed in a private, quiet space with minimal background noise.

What We Offer

• Competitive compensation package including salary commensurate with experience
• Remote work flexibility with a results-driven culture
• Comprehensive health benefits that reflect our commitment to wellbeing
• The chance to directly transform lives and makes treatment accessible
• Collaborative and innovative work environment with a team passionate about our mission
• Professional development opportunities and support for continued growth