Utilization Review Coordinator

Socket.dev

Allentown (Lehigh County)

On-site

USD 42,000 - 48,000

Full time

14 days+

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Benefits offered by this job

Medical, Dental, and Vision Insurance

401(k) with Company Match

Tuition Reimbursement

Paid Time Off

Life Insurance

Flexible Spending Accounts

Employee Recognition Programs

Referral Bonus opportunities

Job summary

Pyramid Healthcare, Inc. in Allentown, PA is hiring a Utilization Review Specialist to perform admission, continued stay and discharge reviews for managed care clients, while maintaining eligibility data and supporting funding accuracy.

The role requires an Associate Degree or higher (Bachelor in Behavioral Health preferred) and 3-5 years in Utilization Review or related healthcare positions, with strong Excel and communication skills to ensure confidentiality and effective problem solving.

Qualifications

Associate Degree or equivalent required; Bachelor of Science in Behavioral Health preferred.
3-5 years’ experience in Utilization Review or related position in a healthcare setting.
Intermediate computer skills including Microsoft Office and data entry.

Responsibilities

Perform admission, continued stay and discharge reviews on all managed care clients.
Maintain positive relationships with referral sources and insurance companies.
Track admissions, continued stay and discharge ASAM requirements for county referrals.
Maintain current insurance eligibility information through EVS, Navinet, etc.
Monitor Census for accuracy of funding.
Attend clinical staffing to obtain information for client reviews.
Maintain daily UR database accurately.
Perform Act 106 reviews and follow up appeals.
Track all county referrals for documentation of admission calls.
Maintain and participate in chart reviews to ensure proper paperwork is in place.
Work directly with Billing Department to reduce uncovered days of funding.
Report to the Assessment Manager on a weekly basis.
Manage all self-pay clients and clients with copays, deductibles, coinsurance and liabilities.
Reduce client balances.

Skills

Utilization Review

Data entry (Excel)

Microsoft Office

Communication skills

Confidentiality

Problem solving

Education

Associate Degree

Bachelor of Science in Behavioral Health

Tools

Excel

Word

Job description

Pyramid Healthcare is dedicated to offering the highest quality of care to those we serve. A focus on client-focused care establishes our family of brands as respected leaders in addiction treatment, mental health recovery and eating disorder treatment modalities.

Pyramid Healthcare offers comprehensive behavioral healthcare defined by supportive environments that offer patients the strength they need to overcome life’s challenges. We offer behavioral healthcare services – psychiatry, addiction recovery, mental disorder treatment, etc. – that allow clients at all stages of recovery or rehabilitation to reclaim health and well-being.

Deliverables/Principal Results Expected:

Perform admission, continued stay and discharge reviews on all managed care clients.
Maintain positive relationships with referral sources and insurance companies.
Track admissions, continued stay and discharge ASAM requirements for county referrals.
Maintain organized system of reporting to counselors when ASAM’s are due and when review calls are to be made.
Maintain current insurance eligibility information through EVS, Navinet, etc.
Monitor Census for accuracy of funding.
Attend clinical staffing to obtain information for client reviews.
Maintain daily UR database accurately.
Perform Act 106 reviews and follow up appeals.
Track all county referrals for documentation of admission calls.
Maintain and participate in chart reviews to ensure proper paperwork is in place.
Work directly with Billing Department to reduce uncovered days of funding. Investigate cases with insurance and referral sources to recuperate lost days of funding.
Report to the Assessment Manager on a weekly basis.
Manage all self-pay clients and clients with copays, deductibles, coinsurance and liabilities.
Reduce client balances.
Other duties as assigned.

Technical Competencies:

Provide the company with accurate information to ensure full financial coverage for each client day. Provide the referral source(s) with timely information to ensure good customer focus. Maintain client confidentiality and provide a safe therapeutic treatment. Knowledge of local, state and federal regulations. Knowledge of facility contracts and agreements. Knowledge of medical terminology, appeal and denial process, composition of medical records. Knowledge of data entry (primarily Excel) and mathematics. Knowledge of pre-certification process and ASAM. Knowledge of CARF standards, release of information and confidentiality. Knowledge of DSM V, private care managers and county referral sources.

Education, Experience:

Associate Degree or equivalent required; Bachelor of Science in Behavioral Health. Intermediate knowledge of computer skills and the internet, Microsoft Office experience, Excel- Intermediate level, Word- Intermediate level. 3-5 years’ experience in Utilization Review or related position in a healthcare setting.

Job-related Behavioral Characteristics:

Demonstrates professionalism, leadership, confidentiality, strong social communication skills, time-management, organized. Must possess skills to communicate effectively and interact well with people of diverse backgrounds. Excellent oral and written communication and interpersonal skills. Ability to problem solve by gathering and analyzing information, working well in an individual/ group problem solving situation, and showing initiative in problem solving. Maintains professionalism and does not show favoritism. Maintains consistency with clients, staff, visitors, and the public. Ability to handle a crisis situation and react appropriately. Flexibility and adaptable. Ability to make decisions in an objective and ethical manner. Calm and decisive in crisis situations. Ability to sustain a team environment, drive continuous improvement projects, confidentiality, excellent problem-solving skills and excellent communicator within the team framework. Self-starter, takes initiative.

The starting compensation for this role is $20/hour; final compensation will be determined based on skills, experience, and qualifications.

Pyramid CORE Values:

We are committed and proud to live our CORE values and use them to inspire those around us. Our employees are expected to align with these values, behaviors, and standards. We are held accountable for upholding these CORE Values: INTEGRITY is striving to be honest, transparent, and ethical when dealing with clients, staff, and the community. DEDICATION is demonstrating an unwavering commitment to always provide exceptional care and support to those we serve is needed daily. COLLABORATION is a steadfast, team-focused approach; working together to achieve excellence. PASSION is genuine, compelling, and relentless desire to improve lives and support Pyramid Healthcare’s mission.

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