Utilization Review Clinician - Pacific hours

Monte Nido; Miami (FL); Remote; USD 60,000 - 90,000; Full time

Job summary

A leading company specializing in eating disorder treatments seeks a Utilization Review Clinician to handle authorizations and support treatment teams. This role requires a master’s degree and relevant experience, with a focus on advocacy for clients' access to care. The position offers remote work options and comprehensive benefits.

Benefits

Competitive compensation

Medical, dental, and vision insurance coverage

Retirement plan

Company-paid life insurance

Paid time off

Professional development

Qualifications

• Master’s degree in counseling, social work or related field preferred.
• Licensed and currently registered in the state strongly preferred.
• Minimum of one year of experience in facility-based care.

Responsibilities

• Manage all authorizations for designated programs including peer-to-peer reviews.
• Support treatment teams by discussing services covered by the member's benefits.
• Engage in clinical rounds as an active treatment team member.

Skills

Communication

Knowledge of Medicare

Knowledge of Medicaid

Proficiency in written skills

Education

Master’s degree in counseling, social work or related field

Bachelor’s Degree in nursing

Job description

Grow with us!

Utilization Review Clinician

Monte Nido

Remote - Pacific hours

Monte Nido has been delivering treatment for eating disorders for over two decades. Our programs offer a model of treatment that blends medically sophisticated care with a personalized treatment approach. Our work is grounded in evidence-based strategies for adults and adolescents suffering from eating disorders. We work from a multi-disciplinary treatment team approach while integrating state-of-the-art medical, psychiatric, nutritional, and clinical strategies to provide comprehensive care within an intimate home setting.

The Utilization Review Clinician is responsible for conducting daily administrative and professional support that enables claims to be correctly processed and retained in accordance with departmental policies and procedures. The specific functions performed by this role are critical in achieving the Revenue Cycle Team’s overall responsibilities involving timely billing and account follow-up.

#LI-REMOTE

Total Rewards:

Discover a rewarding career with us and enjoy an array of comprehensive benefits! We prioritize your success and well-being, providing:

• Competitive compensation
• Medical, dental, and vision insurance coverage (Benefits At a Glance)
• Retirement
• Company-paid life insurance, AD&D, and short-term disability
• Employee Assistance Program (EAP)
• Flexible Spending Account (FSA)
• Health Savings Account (HSA)
• Paid time off
• Professional development
• And many more!

We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Responsibilities Include:

Complete and manage all authorizations for designated programs & departments including single case agreements, prior authorization, continued stay, change in level of care, discharge, peer-to-peer, and manage denials through all levels of appeal.

Support treatment team members & Admissions by discussing services covered by the members benefits and reviewing clinical documentation needed to successfully advocate for our clients.

Engage in clinical rounds as an active treatment team member providing payor needs for next review, guidance on level of care recommendations, and feedback on what will be needed for authorization of clinically indicated services.

Expectation to provide coverage support across all Admission Hubs and UM Department staff as needed.

Responsible for supporting Admissions and program treatment team members in understanding how payors determine medical necessity, documentation needs, auth process, and determination timeline to provide the highest level of advocacy and efficiency possible.

Understanding of Medicare medical necessity criteria.

Communicates with Revenue Cycle Management and Contracting regarding billing/claims issues and status of single case agreements as needed.

Communicates with admissions and programs regarding status of client authorization, potential denials, and potential for private payment.

Leverage understanding of medical necessity criteria and current behavioral health insurance landscape in verbal and written communications with payors to maximize our clients’ access to care and decrease peer to peer reviews.

Follows standardized processes and clinical documentation.

Communicates emerging trends with insurance companies to Clinical Director.

Contribute to department projects and maintain reporting requirements.

Apply understanding of payors medical necessity criteria in communications with payors.

Maintain up to date knowledge of parity, payor & market trends, Medicaid and Medicare benefits, plan structure, and medical necessity criteria.

Maintain up to date knowledge of all MN programs, treatment innovations, and research.

Deliver care in a non-judgmental and non-discriminatory manner, sensitive to patient and staff diversity.

Other Duties and Responsibilities

Attends in-services and educational training as necessary and as assigned.

Seeks out learning experiences and incorporate new knowledge into practice.

Maintains flexibility and adaptability to expected and unexpected changes in the work environment.

Reports incidents, accidents, and occurrences in accordance with policies and procedures.

Maintains safety of the physical environment.

Complies with facility policies and procedures.

Ensures all interactions (phone, email, meetings, etc.) are in line with the organization’s mission and values.

Performs other tasks, as assigned.

Qualifications:

• Master’s degree in counseling, social work or an LMSW, LCSW, LICSW, LPC, LMHC, or Bachelor’s Degree in nursing preferred.
• Licensed and currently registered in the state you are working strongly preferred.
• A minimum of one year of experience of facility based careand knowledge relating to utilization review methods, insurance authorizations, Medicare, Medicaid, and managed care preferred.
• Knowledge of The Joint Commission standards.
• Knowledge of the Principles and Practices of the discipline.
• Knowledge of Joint Commission Standards.
• Demonstrates Proficiency in Communication & Written skills.
• Working knowledge of State & Federal Statutes Regarding Patient Confidentiality laws.
• Knowledge of Drug-Free Workplace Policies.
• Knowledge of Workplace Violence.

#montenido

#montenido