Utilization Review Specialist

Join our team today and immerse yourself in a rewarding career for years to come!

As the Utilization Review Specialist, you will work in an office based setting located in Trenton, Mercer County NJ.


The Utilization Review Specialist is responsible for all aspects of the authorization of treatment via insurance and managed care companies. The Utilization Review Specialist provides appropriate client information to payers regarding the medical necessity of treatment in a timely manner. The Utilization Review Specialist will also perform pre-certification reviews, concurrent reviews and will perform appeal reviews as needed.

Pay: $55,000

Schedule: Full-time; Monday-Friday 8:30am-5:00pm; 30 min unpaid lunch

Responsibilities:

• Requesting and obtaining prior authorizations for treatment services from entities including, but not limited to, Medicaid, Managed Care Organizations, NJSAMS, Commercial Insurance, EAP, etc..
• Facilitating prior authorization requests and concurrent reviews with all payer sources for clients enrolled in services that require authorizations for care.
• Managing and tracking prior authorization approvals and requests for all clients enrolled and ensuring prior authorization/approval for services are obtained in a timely manner from payer sources to ensure no gaps in care or coverage.
• Coordinating with program leadership and staff to ensure clinical documentation (Progress notes, Treatment Plans, etc..) is completed timely and contains sufficient clinical content for prior authorization services.
• Engaging in Continued Stay Reviews with program leadership and staff to determine justification for continuation of care.
• Coordinating with Accounts Receivable and Program Leadership to manage and track all outgoing requests and receipts of authorizations as well as managing pending requests.
• Verifying insurance coverage for enrolled clients and coordinating with program leadership and AR to ensure there is a source of payment for all clients receiving care.
• Facilitating Presumptive eligibility process for eligible clients.
• Other duties as assigned.

Benefits:

• Competitive salary
• Supplemental income
• Medical, Dental, Vision, 403(b)
• Generous paid time off benefits
• Opportunity for personal and career growth
• Team oriented environment – we practice the FISH! Philosophy

Qualifications:

• Bachelor's Degree required in psychology/human services/nursing/healthcare or related field; Master's Degree Preferred in Behavioral Health/HealthCare or related field; OR LPN or RN
• Minimum 2 years of relevant experience in a behavioral health or healthcare setting.
• Knowledgeable about behavioral health services including ambulatory services such as Outpatient, Partial Care, and Addictions treatment.
• Knowledgeable about healthcare claims and processing including prior authorizations, CPT codes, MCOs, Medicaid, etc..
• Proficient in use of technology, various applications including Microsoft Office (including Excel), Electronic Health Records, and other data bases such as NJSAMs and Navinet.
• Strong skills related to clinical documentation
• Strong organizational and time management skills
• Excellent written and verbal communication, as well as interpersonal skills.
• Valid driver’s license in good standing required.

All positions require a valid driver’s license in good standing, and pre-employment drug screening. All candidates, if hired, will be expected to cooperate with Oaks Integrated Care and The Department of Human Services in all inspections and investigations. Oaks Integrated Care considers applicants for all positions without regard to: race; color; religion; sex; national origin; age; sexual orientation; marital or veteran status; the presence of a medical condition, genetic information or handicap, unrelated to performing the tasks of the job; or any other legally protected status.

Equal Opportunity Employer


This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.