Remote Behavioral Health Utilization Specialist

Nationwide Children's Hospital; Columbus (OH); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Nationwide Children’s Hospital is seeking a Behavioral Health Utilization Review Specialist to review cases, determine medical necessity, and ensure compliance with guidelines. The role conducts pre-certifications, pre-authorizations, and retrospective reviews, collaborating with clinical staff and payers.

After a 90-day in-office training period, the position offers work-from-home options. Candidates should have a Bachelor’s degree in Social Work, Psychology, or a related field, with at least

Qualifications

• Bachelor’s degree in Social Work, Psychology, or related field required.

Responsibilities

• Conducts utilization reviews to determine medical necessity and adherence to clinical guidelines.
• Communicate with care teams and payors to ensure quality care and optimum payment.
• Assist with retrospective reviews and denial management.
• Document case reviews and maintain accurate records of clinical activities.
• Provide education and support on UR/UR management processes.
• Analyze clinical data to identify trends impacting patient care; participate in quality improvement.
• Facilitate reimbursement by communicating with payers, staff, patients, and families about funding status and actions.

Skills

Communication

Customer service

CMS knowledge

Payer web apps

Education

Bachelor’s degree in Social Work, Psychology, or related field

Job description

Nationwide Children’s Hospital is seeking a Behavioral Health Utilization Review Specialist to review cases, determine medical necessity, and ensure compliance with guidelines. The role conducts pre-certifications, pre-authorizations, and retrospective reviews, collaborating with clinical staff and payers.

After a 90-day in-office training period, the position offers work-from-home options. Candidates should have a Bachelor’s degree in Social Work, Psychology, or a related field, with at least