Utilization Review Specialist - (40 hours 8a-4p)

Gosnold; United States; Remote; USD 65.000 - 90.000; Vollzeit

Benefits dieser Stelle

Blue Cross & Blue Shield health and/or

Vision insurance

Flexible spending accounts (Medical/De

Paid vacation, sick and holidays

403b retirement savings with employer1

Personal financial management services

Life and supplemental life insurance

Critical illness and accident coverage

Employee Assistance Program

Pet insurance

Tuition assistance

Zusammenfassung

Gosnold is seeking an Utilization Review Specialist to perform pre-certification and concurrent reviews, working closely with clinical teams to coordinate care and ensure patient coverage. The role requires strong communication with Patient Financial Services and meticulous documentation of UR data.

Ideal candidates will have a relevant Bachelor's degree and at least two years of clinical experience in health services, with knowledge of levels of care and medical criteria.

Qualifikationen

• Bachelor's degree in nursing, social work, psychology, mental health or addiction required.
• Experience in utilization review and/or clinical services in an intensive treatment setting preferred; at least 2 years of clinical experience.
• Knowledge of clinical criteria for various levels of care.

Aufgaben

• Perform utilization review of pre-certification and concurrent clinical utilization reviews.
• Communicate daily with Patient Financial Services to ensure patient coverage.
• Collaborate with interdisciplinary treatment teams to coordinate care and authorizations.
• Consult with clinical staff to update intervention strategies and continued care authorizations.
• Document authorizations and UR results in the computer system and report progress to teams.
• Educate treatment teams about member benefits and aid in arranging aftercare.

Kenntnisse

Communication

Interpersonal skills

Organizational skills

Computer literacy

Ausbildung

Bachelor's degree in nursing, social work, psychology, mental health or addiction

Jobbeschreibung

SUMMARY:

The Utilization Review Specialist will perform utilization review of pre-certification and concurrent clinical utilization reviews with insurance companies in accordance with certification requirements of each patient’s insurance plan. This position requires daily communication with Patient Financial Services to ensure that every patient is covered for their stay. The Utilization Review Specialist must have experience working on interdisciplinary treatment teams.

ESSENTIAL JOB FUNCTIONS/DUTIES/RESPONSIBILITIES:

• Working knowledge of managed care principles with preference for experience in behavioral health.
• Consult with clinical staff to coordinate recommendations for intervention strategies and authorizations for continued care.
• Provide technical assistance to staff with care coordination activities as needed.
• Prepare and present cases for physician when necessary for doctor-to-doctor reviews.
• Document and record authorizations and UR results in the computer system. Record and report to treatment teams the progress and expectations for the next UR review.
• Daily communication and education with the treatment teams about the member’s insurance benefits and aid them in coordinating the most comprehensive after care for the patient.
• Provide information to managed care providers about alternative levels of care within the Gosnold system and accurately promotes these services.
• Perform all other duties as assigned.

SUPERVISORY RESPONSIBILITIES:

N/A

MINIMUM KNOWLEDGE, Experience, AND SKILLS REQUIRED:

• Education: Bachelor’s degree in nursing, social work, psychology, mental health or addiction required.
• Experience: Experience in performing utilization review and/or providing clinical services in an intensive treatment setting is preferred and at least (two) 2 years of clinical experience in delivery of health services. Knowledge of clinical criteria required for various levels of care.
• Skills: Computer literacy and ability to learn and use behavioral health software programs. Good communication, interpersonal, and organizational skills.

Certificates, Licenses, and Registrations: N/A

BENEFITS (based on full-time employment):

• Blue Cross & Blue Shield health and dental insurance
• Vision insurance
• Medical and dependent care flexible spending accounts
• Generous paid vacation, sick, and holiday time
• 403b retirement savings plan with employer match
• Personal financial management services
• Life and supplemental life insurance
• Critical illness and accident insurance
• Employee Assistance Program
• Pet insurance
• Tuition assistance

Gosnold is an Equal Opportunity Employer.