Utilization Review Specialist

Coronis Health; Jackson (MI); Remote; USD 60,000 - 62,000; Full time

Job summary

Coronis Health is seeking a qualified Utilization Review Specialist to manage authorization of treatment with insurance and managed care companies from a remote Jackson, MI area. You will provide information to payers about medical necessity and perform pre-certification and concurrent reviews.

You will liaise with hospitals and providers, ensure compliance with state and federal regulations, maintain patient confidentiality, and participate in audits.

Qualifications

• Three to Five (5) years’ experience in Case Management/Utilization Review; Prior UR experience in a Substance abuse environment is mandatory.
• Knowledge of ASAM guidelines and accreditation/licensure requirements (RN, LCSW, LPN, LMFT).
• Ability to communicate clearly with supervisors, staff and facilities; maintain confidentiality.

Responsibilities

• Act as liaison with insurance/managed care for authorization of treatment costs.
• Provide necessary patient information to payers to justify medical necessity.
• Perform pre-certification, concurrent, and appeal reviews as needed.
• Ensure compliance with State and Federal regulations and protect patient confidentiality.
• Utilize data to present findings using established methods; participate in staff meetings.

Skills

Case Management

Utilization Review

ASAM guidelines

Verbal & Written Communication

Medical Terminology

State & Federal Privacy Laws

Supervising staff

Stress management

Adaptability

Lifting 20 lbs

Education

RN or LCSW or LMHC or LMFT or CADC/LAADC

Job description

Job Description

Remote- Work From Home, Jackson, Jackson, Michigan, United States

Exempt

Location

USA/Remote

Reports to

UR Director

FLSA Classification

Exempt

Full-Time or Part-Time

Full-Time

Salary Range

$60,000-62,000

* Starting pay varies based on location and experience, in compliance with specific state wage regulations. Competitive rates tailored to your geography and expertise.

Position Overview

The Utilization Review Specialist is responsible for all aspects of the authorization of treatment via insurance and managed care companies. The Utilization Review Specialist provides appropriate client information to third party payers regarding the medical necessity of treatment in a timely manner. The Utilization Review Specialist will also perform pre-certification reviews, concurrent reviews and will perform appeal reviews as needed.

Key Responsibilities

• Act as agency liaison with insurance and managed care companies for authorization of treatment costs, representing company in a positive manner in the professional Participate in staff meetings as needed
• Clear communication with supervisors, co-workers, and facilities
• Keeps abreast of changes to, and monitors compliance with, State and Federal laws and regulations in areas of insurance/ third party payers
• Protects the confidentiality of patients and the privacy of staff
• Uses a computer to type correspondence, reports and other items as requested, ensuring that typing is accurate
• Process data in conjunction with compliance consultants in order to present it effectively using established statistical methods
• Demonstrates the willingness to accept responsibility
• Performs other duties as assigned by the Director of Utilization Review

Qualifications

• Three to Five (5) years’ experience in Case Management/Utilization Review (as either CADC, LAADC, RN, LCSW, LPN, LMHC, LMFT, RN Case Manager, or Utilization Review Coordinator). Prior Utilization Review experience in a Substance abuse environment is mandatory.
• Knowledge of ASAM guidelines.
• Knowledge of accreditation and licensure requirements (RN, LCSW, LPN, LMFT) in accordance with state agencies.
• Ability to establish rapport with and supervise employees as well as professional staff and peers
• Ability to work under stressful conditions and is flexible in relation to department needs.
• Knowledge of medical terminology.
• Demonstrates proficiency in Verbal & Written Communication
• Knowledge of State & Federal Statutes Regarding Patient Confidentiality Laws.
• Knowledge of Drug-Free Workplace Policies. Knowledge of Corporate Integrity & Compliance Program.
• Knowledge of state guidelines and accreditation agency standards
• Ability to lift a minimum of 20 lbs.

Additional information

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities, and working conditions may change as needs evolve.

Coronis Health is committed to creating a diverse and inclusive environment where all employees are treated fairly and with respect. We are an equal-opportunity employer, providing equal opportunities to all applicants and employees regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other protected characteristic. We welcome and encourage applications from candidates of all backgrounds.