Utilization Review Specialist - Autism

Nationwide Children's Hospital; Columbus (OH); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Nationwide Children’s Hospital is seeking a Behavioral Health Utilization Review Specialist to review cases, determine medical necessity, and ensure compliance with guidelines. The role conducts pre-certifications, pre-authorizations, and retrospective reviews, collaborating with clinical staff and payers.

After a 90-day in-office training period, the position offers work-from-home options. Candidates should have a Bachelor’s degree in Social Work, Psychology, or a related field, with at least

Qualifications

• Bachelor’s degree in Social Work, Psychology, or related field required.

Responsibilities

• Conducts utilization reviews to determine medical necessity and adherence to clinical guidelines.
• Communicate with care teams and payors to ensure quality care and optimum payment.
• Assist with retrospective reviews and denial management.
• Document case reviews and maintain accurate records of clinical activities.
• Provide education and support on UR/UR management processes.
• Analyze clinical data to identify trends impacting patient care; participate in quality improvement.
• Facilitate reimbursement by communicating with payers, staff, patients, and families about funding status and actions.

Skills

Communication

Customer service

CMS knowledge

Payer web apps

Education

Bachelor’s degree in Social Work, Psychology, or related field

Job description

Schedule: Monday-Friday (8:00am-4:30pm) Position is work from home after a 90 day in-office training period.

Job Description Summary

Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.

Essential Functions

• Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
• Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
• Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
• Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
• Provides education and support regarding utilization review and management activities and processes.
• Analyzes clinical data to identify trends and patterns that may impact patient care. Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
• Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.

Education Requirement

Bachelor’s Degree in Social Work, Psychology, or related field, required.

Licensure Requirement

(not specified)

Certifications

(not specified)

Skills

• Excellent written and verbal communication and interpersonal skills.
• Excellent customer service and organizational skills.
• Working knowledge of CMS and other review agency standards.
• Proficient with software applications including CM, payer web applications, MITS, and others.

Experience

• Three years of behavioral health experience, required.
• One year of experience in pediatric care or services, required.
• Utilization review or utilization management experience, preferred.

Physical Requirements

OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing – Far/near, Sitting

Additional Physical Requirements Performed But Not Listed Above

(not specified)

"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"