Full Time Utilization Review Specialist

Canyon Vista; Mesa, Northern (AZ, KY); Hybrid; USD 33.000 - 40.000; Vollzeit

Zusammenfassung

Canyon Vista Recovery Center is seeking an Utilization Specialist in Mesa, AZ to manage admissions reviews, concurrent stays, and discharge planning. You will coordinate with insurers to obtain authorizations and document medical necessity while supporting staff with charting requirements.

Preferred candidates have ASAM experience and a clinical background in substance abuse, with emphasis on accurate documentation and efficient appeals handling.

Qualifikationen

• Clear communication with insurers and providers.
• ASAM experience or familiarity preferred.
• Experience in utilization review is preferred.
• Clinical background in substance abuse beneficial.

Aufgaben

• Review admissions, concurrent stays, and discharge planning per criteria.
• Coordinate with insurers for authorization and appeals.
• Notify and educate staff on documentation and charting requirements.
• Support pre-certifications and benefit verification with managed care organizations.

Kenntnisse

Communication skills

ASAM experience

Utilization review knowledge

Interpersonal skills

Ausbildung

Bachelor's degree in nursing or related health field

LPN or RN licensure in state

High School diploma or equivalent

Jobbeschreibung

**About the Job:**PURPOSE STATEMENT: The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information; Educates hospital staff about requirements and trends. Schedule: Mon-Fri 8am-4:30p Compensation: $24/hr-$29/hr BOE**Roles and Responsibilities:****ESSENTIAL FUNCTIONS:*** Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicates effectively with insurance companies, health maintenance organization (HMOs) and other similar entities for approval of initial or additional days for treatment. Provides information they need in a logical, concise manner using technical language that accurately describes client’s condition and need for hospitalization.* Communicates directly with physicians and other providers with respect to specific inquires and perceived trends of issues as they relate to utilization management.* Appeals all denials ensuring accuracy of information and effective coordination of correspondence. Initiates, coordinates, and monitors the appeal process. Provides information to physicians to assist them in their role in appeals.* Assists the admissions department with pre-certifications of care. Performs pre and post admission benefit verification with managed care organizations.* Maintains accurate documentation and files as it relates to utilization management.* Provides ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.* Communicates effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each instance to determine if corrective action was taken. Notifies supervisor if corrective action is not completed.* Coordinates information and findings with the business office to help recognize or resolve possible payment problems.* Monitors client length of stay and extensions and informs clinical and medical staff on issues that may impact length of stay. Investigates short term length of stays and endeavor to create alternate financial planning which would offer the client extended days of treatment. Participates in discharge planning as required.* Gathers and develops statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.* Conducts quality reviews for medical necessity and services provided. Facilitates peer review calls between facility and external organizations. Identifies potential review problems and discuss them with multi-disciplinary team and/or administration.* Acts as liaison between managed care organizations and the facility professional clinical staff.* Assists with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.**EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:*** High School diploma or equivalent required. Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field preferred.* One or more years of direct clinical experience in a substance abuse setting required and ASAM experience preferred.* At least one year experience in utilization review preferred.**LICENSES/DESIGNATIONS/CERTIFICATIONS:**Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.**SUPERVISORY REQUIREMENTS:**This position is an Individual Contributor.Why Canyon Vista Recovery Center?Canyon Vista Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Canyon Vista Recovery Center is an EOE.