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Utilization Review Specialist

Job Summary:

The Utilization Review Specialist is responsible for obtaining authorization from payors. Under general supervision, they review records for levels of care and contact payors based on the verification of benefits. The UR Specialist is responsible for upkeep of spreadsheets relating to days authorized and next review dates.  They assess continued treatment for clients that do not require authorization, and contact the facilities for more information as needed. The UR Specialist also contacts insurance companies through web based programs, forms, and internet websites to obtain needed authorizations.

Essential Functions:

  • Promote the mission, vision, and values of the organization.
  • Communicate with facilities in order to obtain authorizations.
  • Document into spreadsheets, dates and times contact was made to facilitate authorization. 
  • Manage incoming emails, faxes, and attend to multiple tasks at once.
  • Understand and communicate the verification of benefits to facility if the need arises.
  • Manage calendar to schedule appointments with various case managers from insurance companies. 
  • Understand billing processes.
  • Understand the retro authorization and appeal process.
  • Facilitate and undertake peer reviews, or peer review scheduling.
  • Collaborate with facility treatment teams, to manage the clients level of care.
  • Understand medical necessity as it pertains to insurance authorizations, levels of care, and appeals. 
  • Provide discharge referrals as needed to facilities.
  • Provide discharge information to insurance.

Working Knowledge Of:

  • Medical Necessity as it applies in Behavioral Health Care
  • ASAM Guidelines
  • ICD 10 Coding

Ability To:

  • Communicate effectively in oral or written formats
  • Maintain confidentiality regarding patient privacy standards/HIPAA
  • Work Independently/Remotely
  • Use Good Judgement in order to make critical decisions
  • Use time management skills in high stress environment