Utilization Review Specialist

The Utilization Review Coordinator plays a critical role in ensuring that patients at our facility receive the appropriate level of care while managing treatment costs. This position involves coordinating, assessing, and authorizing treatment plans, collaborating with medical staff, and maintaining compliance with healthcare regulations. The Utilization Review Coordinator works closely with insurance companies, clinicians, and support staff to ensure that treatment plans are clinically appropriate and reimbursable, advocating for the best interests of the patients and the hospital.

Key Responsibilities:

1. Case Review and Assessment
   • Conduct daily reviews of patient charts, treatment plans, and progress notes to determine if the level of care provided aligns with clinical guidelines and insurance requirements.
   • Monitor patient progress, reassess treatment needs, and recommend adjustments in care levels as needed.
   • Collaborate with clinical teams to understand patient needs, assess treatment efficacy, and make informed recommendations.
2. Insurance Coordination
   • Act as the primary point of contact with insurance providers for treatment authorization, concurrent review, and appeal processes.
   • Submit required documentation to insurance companies in a timely manner, including clinical updates, to secure and maintain treatment authorization.
   • Resolve reimbursement issues, advocating for patient treatment needs and securing necessary approvals.
3. Documentation and Compliance
   • Ensure all documentation is complete, accurate, and in line with state, federal, and hospital policies to facilitate compliance and quality audits.
   • Maintain a working knowledge of current insurance guidelines, DSM-5 criteria, and ASAM (American Society of Addiction Medicine) criteria.
   • Participate in internal and external audits, preparing records and reports as necessary.
4. Collaboration and Communication
   • Work closely with medical and support staff to ensure continuity of care and that utilization review processes are aligned with patient needs.
   • Provide guidance to clinical staff regarding documentation best practices and criteria required for continued care authorizations.
   • Participate in multidisciplinary team meetings to discuss patient care plans, discharge planning, and treatment adjustments.
5. Quality Improvement
   • Identify trends in denied claims or treatment authorizations, providing recommendations for process improvements.
   • Assist in training hospital staff on utilization review processes, criteria for different levels of care, and effective documentation practices.
   • Collaborate in developing policies to improve efficiency, patient care outcomes, and financial performance.

Qualifications:

• Education: Bachelor’s degree in Nursing, Social Work, or a related field required. Master’s degree in a health-related field preferred.
• Experience: Minimum of 2 years in utilization review, case management, or related field, preferably within a behavioral health or chemical dependency setting.
• Licensure: Current RN, LCSW, or LPC license preferred.
• Skills and Competencies:
  • In-depth understanding of mental health, substance abuse treatment and ASAM criteria.
  • Strong analytical and critical thinking skills with the ability to make clinical judgments based on patient data.
  • Excellent communication and interpersonal skills to facilitate interactions with insurers, staff, and patients.
  • Proficiency with electronic medical records (EMR) and utilization review software.
  • Knowledge of state, federal, and industry regulations related to chemical dependency and mental health care.

Working Conditions:

• Full-time, primarily daytime hours, with occasional on-call duties or weekends as needed.
• Must be able to work in a high-paced environment and handle sensitive information with discretion.
• Physical demands may include sitting for extended periods, light lifting, and using a computer for most of the workday.