Utilization Review Specialist

New Horizons of the Treasure Coast; United States; Hybrid; USD 55,000 - 75,000; Full time

Job summary

New Horizons of the Treasure Coast seeks a Utilization Review Specialist to manage patient authorization processes, review records in EMR, and secure timely pre-certifications via telephone or provider portal. The role is hybrid, balancing on-site and remote duties within a compliant case management framework.

The ideal candidate will hold a high school diploma, demonstrate strong organizational, verbal, and written communication skills, and may have an associate or bachelor’s degree.

Qualifications

• High School diploma or equivalent required.
• Organizational skills.
• Verbal and written communication skills.
• Associate or Bachelor’s degree preferred.
• Paramedic, EMT or Nursing Assistant certification preferred.

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

Education

High School diploma or equivalent

Associate degree

Bachelor’s degree

Job description

New Horizons is the largest mental health and addiction recovery provider on the Treasure Coast (and beyond), serving 15,000 children and adults annually through inpatient crisis services, 24-hour help line and mobile response team, and outpatient programs conveniently located across Indian River, Martin, Okeechobee and St. Lucie counties. In addition, New Horizons assists 22,000 students in area schools, and we work closely with the courts, law enforcement, jails, and hospitals to help improve the health of individuals and the quality of life in our community.

New Horizons is seeking an Utilization Review Specialist, who will be responsible for following up on patient accounts when authorization for stay is required, initiate pre-certification timely via telephone or provider portal, review patients medical record via EMR to ensure criteria for the appropriate level of care is met, and provide clinical to insurance company to obtain authorization. This position is considered a Hybrid role.

As a Utilization Review Specialist, your responsibilities will include:

• 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

Requirements

REQUIRED

• High School diploma or equivalent required.
• organizational skills,
• verbal and written communication skills,

Preferred

• Associate or Bachelor’s degree preferred.
• Paramedic, EMT or Nursing Assistant certification preferred.