Billing Specialist and Utilization Review for Recovery Clients

Apploi; Nashville (TN); On-site; USD 52,000 - 64,000; Full time

Job summary

Apploi in Nashville is seeking an Utilization Review and Support Specialist to work with leadership and clinical staff to manage precertification and concurrent reviews, insurance billing, and reporting.

Responsibilities include auditing records, compiling monthly statistics, and ensuring compliance with TNWITS and insurer requirements; the role supports admissions and clinical teams daily.

Qualifications

• Minimum two years of college or associate degree in a human service-related field or LADAC eligible.
• Minimum two years of experience in substance abuse treatment admissions/medical records.
• Experience conducting insurance precertification and continued stay reviews.
• Experience with client assessments and billing.

Responsibilities

• Verify insurance coverage and benefits according to ASAM/agency criteria.
• Perform precertification and concurrent reviews for residential and intensive outpatient programs.
• Submit insurance billing to managed care organizations and monitor payments/denials.
• Submit required documentation to MCOs and assist with scheduling TNCare discharge appointments.
• Attend payer meetings and report updates to leadership.
• Balance TNWITS encounters weekly and reconcile SRC database monthly.
• Conduct Level I record audits and interview clients for pre-screening.
• Prepare utilization management and statistical reports for the PSO.
• Participate in Professional Staff Organization meetings.

Skills

Substance abuse treatment admissions

Medical records

Insurance precertification

Continued stay reviews

Client assessments

Billing

Education

Associates degree or two-year college in human services

Job description

Utilization Review and Support Specialist

Classification:

Full-time, non-exempt

Minimum Qualifications:

Minimum two years of college or associate degree in a human service-related field or LADAC eligible. Minimum two years of experience working in substance abuse treatment admissions/medical records. Demonstrated experience conducting insurance precertification and continued stay reviews, client assessments, and billing.

Job Summary:

Responsible for working collaboratively with the Leadership and Agency Departments to conduct precertification and concurrent reviews with insurance organizations, managing insurance billing, compiling monthly reports, completing state billing (TNWITS), and auditing client electronic and paper records. Consistently maintain client and program-related records per agency standards; collect data and prepare statistical reports; Provide support services to clinical and admissions staff as required; and perform other related duties as required.

Duties:

• Verify client insurance coverage and benefits
• Works collaboratively with the various departments utilizing ASAM criteria to complete thorough and timely precertification and continued stay reviews for residential and intensive outpatient programs. Communicate pre-certification and review information to clinical and admissions staff.
• Submit insurance billing information to managed care organizations, and monitor payments and denials of payment.
• Submit all required documentation to managed care organizations, including PINs, discharge summaries, and release of information forms. As needed, assist the clinical team in scheduling required TnCare discharge appointments.
• Attend TnCare and third party payer meetings, keep informed of changes in the insurance industry, and report updates to the Director.
• Manage and conduct state billing in TNWITS system. Batch and enter TNWITS encounters weekly. Balance the SRC database to TNWITS monthly, submit invoices to the SRC Administrative Assistant, and submit corrections if needed.
• Conduct Level I record audits for per applicable agency policy and procedure.
• Interview clients on the telephone for pre-screening and assist admissions in schedulingscreening appointments.
• Prepare Utilization Management and statistical reports related to all programs for the PSO.
• Participate in Professional Staff Organization meetings

The Employer retains the right to change or assign other duties to this position.