Utilization Review Specialist

Position Summary:

Person in this position is responsible for collecting clinical information and communicating with MCOs in a timely manner in order to advocate for the highest level of care that is supported by the clients acuity, and in compliance with regulations as defined by WestCare and its regulatory and accrediting agencies. Person in the position is also responsible for communicating with insurance companies/payor sources as an advocate for the patients served. Essential functions include those listed below

Essential Job Functions:

• Establish and maintain positive and frequent effective communication with insurance carriers
• Read and understand patient/members running chart narrative and respective case notes and be able to disseminate patient needs and professional/clinical recommendations and communicate this information effectively
• Call in intakes and/or peer to peers and get the patients appropriate level of care authorized
• Obtain and communicate level of care and authorizations and properly enter information into the systems.
• Manually complete and submit quality authorization documentation to insurance companies
• Serve as an advocate for patient members in relation to their care and their insurance benefits
• Responsible for tracking current & concurrent authorization needs in all levels of care
• Responsible for detailed system documentation of accounts
• Communicating with other departments to obtain or provide needed information on patient accounts.
• All other related duties as assigned

Essential Qualifications:

Certifications/Licenses:

• None required

Education:

• Associates or Bachelors level LPN or RN and/or Bachelors or Masters level CADC/LADC with 2 years utilization review experience, preferred experience working with individuals with psychiatric or

substance use disorder

Experience and Competencies:

• Proven experience in conceptualizing a case and creating a clinical impression to present to all involved and approved parties, including managed care representatives
• Knowledge of CPT, ICD 9 & ICD 10 coding, ASAM, medical terminology and EMR/CDS Systems.
• Proficiency in Microsoft Office Platform Applications and knowledge of HIPAA regulations and guidelines.
• Knowledge of managed care and reimbursement principles.
• Understanding and proficiency in State of NV Medicaid Chapter requirements
• Collaboration, negotiation, and assertiveness skills.
• Must be organized, detail oriented and have the ability to focus on several job-specific tasks with several potential surrounding distractions and patient traffic.
• Excellent verbal and written communication skills.
• Critical thinking and problem solving skills.
• Must be able to work in a team environment.
• Ability to perform complex tasks and to prioritize multiple projects.
• Strong analytical and critical thinking skills and the ability to analyze, summarize, and effectively present data.
• Ability to work collaboratively with others in a manner that is pleasant and professional.
• Ability to exercise good judgment and discretion.
• Ability to operate a computer and complete documents in Microsoft program formats.
• Ability to complete work tasks within scheduled work hours.
• Excellent verbal and written communication skills.

Working Conditions:

• Work is performed primarily in a professional, office setting.
• A minimum of 40 hours per week are expected but significantly more hours may be required from time to time. Regular attendance is required.

Essential Physical and Mental Demands of the Job

The employee must be able to perform the following essential duties and activities with or

without accommodation:

Physical Demands:

• Use of computer and telephone systems is required which includes coordination of eye and hand, and fine manipulation by the hands (typing, writing, and working with files).
• Requires talking: Expressing or exchanging ideas by means of the spoken word. Talking is required to impart oral information to employees, clients, and the public, and in those activities in which the employee is required to convey detailed or important spoken instructions to others accurately, loudly, or quickly.
• Requires hearing: Hearing is required to receive and communicate detailed information through oral communication.
• Requires seeing: Clarity of vision at 20 inches or less and at distance. This factor is required to complete paperwork for many of the employees essential job functions and to observe activities in and out of the facility.
• The normal work routine involves no exposure to human blood, body fluids or tissues. However, exposure or potential exposure may be required as a condition of employment. Appropriate personal protective equipment will be readily available to every employee

Mental Demands:

• Requires the ability to collect and analyze complex numerical and written data and verbal information to reach logical conclusions.
• Requires the ability to work and cooperate with clients, co-workers, managers, the public and employees at all levels in order to exchange ideas, information, instructions and opinions.
• Requires the ability to work under stress and in emotionally charged settings.