Hybrid Utilization Review & Care Authorization Specialist

New Horizons of the Treasure Coast and Okeechobee; Town of Florida (NY); Hybrid; USD 45,000 - 60,000; Full time

Job summary

New Horizons of the Treasure Coast and Okeechobee seeks a Utilization Review Specialist to manage patient accounts requiring authorization. Responsibilities include initiating pre-certification, reviewing EMR for care level criteria, and communicating with insurers to obtain approvals.

This hybrid role requires strong organizational, verbal and written communication, and problem-solving skills to ensure compliance with CMS and agency policies.

Qualifications

• High School diploma or equivalent required.
• organizational skills,
• verbal and written communication skills,
• problem solving skills,
• computer literacy.

Responsibilities

• Follow each account during the IP stay and on discharge for authorization - document status in the electronic system,
• Escalate any potential disputes or denial of accounts to Director of Revenue or designee
• Trends disputed claims by payor
• Obtain & follow authorization for Case Management Services
• Adhere to federal, state, payer, and local regulations and accreditation requirements impacting case management scope of services
• Adhere to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and agency policies

Skills

Organizational skills

Verbal communication

Written communication

Problem solving

Computer literacy

Education

Associate or Bachelor’s degree preferred

Paramedic, EMT or Nursing Assistant certification preferred

Job description

New Horizons of the Treasure Coast and Okeechobee seeks a Utilization Review Specialist to manage patient accounts requiring authorization. Responsibilities include initiating pre-certification, reviewing EMR for care level criteria, and communicating with insurers to obtain approvals.

This hybrid role requires strong organizational, verbal and written communication, and problem-solving skills to ensure compliance with CMS and agency policies.