About Zealie
Zealie is a fast-growing Medical Billing Services company specializing in the Behavioral Healthcare industry. Our clients are substance use disorder treatment, addiction recovery, and mental health treatment centers that are saving lives on a daily basis. Our state of the art proprietary technology provides data analytics and revenue prediction tools to our clients to help them make strategic business decisions to grow their business. We are committed to delivering exceptional products and services to our clients and believe that our Utilization Review team plays a crucial role in achieving this mission. We are seeking motivated individuals with a desire to be a part of a winning team.
Job Summary
The Utilization Review (UR) Team Lead is responsible for overseeing the daily operations of the UR team, ensuring that all authorization processes are executed efficiently and in compliance with regulatory standards. This role involves leading and managing a team of UR Specialists, providing guidance, training, and support to ensure high-quality service delivery. The UR Team Lead also plays a pivotal role in collaborating with clinical teams, insurance providers, and facility management to ensure that patient care is aligned with insurance requirements and that all necessary authorizations are secured in a timely manner.
Responsibilities and Duties
- Team Leadership and Management:
- Supervise, mentor, and provide ongoing support to the UR team, ensuring that all team members are performing their duties effectively and in accordance with company standards.
- Conduct regular team meetings to discuss case management strategies, process improvements, and any challenges the team may face.
- Oversee the workload distribution among the team members, ensuring an equitable distribution of cases and timely completion of tasks.
- Process Oversight and Compliance:
- Ensure that all UR processes are followed consistently by the team, including documentation of contact with insurance providers, tracking authorization dates, and maintaining compliance with HIPAA regulations.
- Monitor and audit team performance to ensure adherence to internal protocols and external regulatory requirements.
- Case Management and Escalation:
- Handle complex or escalated cases that require a higher level of expertise or intervention, working directly with insurance providers and clinical teams to resolve issues.
- Facilitate the resolution of any disputes or challenges related to authorizations, retro authorizations, or appeals.
- Training and Development:
- Develop and implement training programs for new and existing UR Specialists, focusing on best practices, compliance standards, and effective communication with insurance providers.
- Provide ongoing professional development opportunities for the team to enhance their skills and knowledge.
- Collaboration and Communication:
- Serve as the primary point of contact between the UR team and other departments, including clinical teams, billing, and facility management.
- Work closely with facility treatment teams to ensure that patient care levels are appropriately managed and that necessary authorizations are in place.
- Reporting and Data Management:
- Generate regular reports on team performance, authorization status, and any trends or issues in the UR process.
- Utilize data to identify areas for process improvement and implement changes to enhance the efficiency and effectiveness of the UR function.
- Patient Advocacy:
- Advocate on behalf of patients to ensure that necessary services are covered by insurance, using in-depth knowledge of medical necessity criteria and insurance protocols.
- Provide support to the team in articulating medical necessity and securing authorizations for services.
Qualifications and Skills
- Experience:
- Minimum of 7-10 years of experience in the Utilization Review process, with at least 3 years in a supervisory or leadership role.
- Strong background in Substance Abuse/Mental Health Treatment, with a thorough understanding of ASAM criteria and medical necessity standards.
- Proven experience in managing clinical appeals and interacting with insurance providers at a high level.
- Education:
- Bachelor’s degree or higher in Psychology, Behavioral Health, or a related field is required.
- Professional licensure or certification (e.g., LCSW, LMHC, LMFT, CAC, CAP, MCAP, MAC) is highly desirable.
- Skills:
- Excellent leadership and team management skills, with the ability to motivate and guide a team towards achieving departmental goals.
- Strong problem-solving and decision-making abilities, particularly in handling complex or escalated cases.
- Advanced proficiency in electronic medical record systems and related UR software (e.g., Kipu, ZenCharts, BestNotes, SunWave).
- Exceptional organizational skills, with the ability to manage multiple priorities and tasks effectively.
- Excellent verbal and written communication skills, with the ability to articulate complex information clearly and effectively.
Additional Preferred Experience
- Experience leading a team in a behavioral health setting, with a focus on utilization review and authorization processes.
- Knowledge of day-to-day operations in psychiatric or behavioral healthcare facilities, including all levels of care (Detox, RTC, PHP, IOP, OP, Aftercare).
- A track record of implementing process improvements that enhance team efficiency and effectiveness.
The UR Team Lead is a crucial role in ensuring that the utilization review process is conducted efficiently, accurately, and in compliance with all regulatory standards. This position requires strong leadership, excellent communication skills, and a deep understanding of the complexities involved in securing insurance authorizations for behavioral health services.
