Utilization Review Specialist

JOB TITLE: Utilization Review Specialist
DEPARTMENT: Utilization Review
REPORTS TO: Utilization Review Coordinator


The Utilization Review Specialist supports Cumberland Heights’ mission of transforming lives, providing hope and healing to persons and their families affected by the disease of addiction.

POSITION SUMMARY
The Utilization Review Specialist is responsible for communicating pertinent information between the organization’s staff and various third party payors and managed care organizations in order to ensure maximum benefit from treatment services and the insurance benefits available.

PRIMARY DUTIES AND RESPONSIBILITIES include the some or all of the following:
1. Processes clinical information from Cumberland Heights staff to third party payors and/or managed care reviewers
a) at the time of impending admission to obtain initial authorization;
b) at specified intervals during the patients’ treatment to report on progress and continued treatment needs, thus obtaining continued stay authorization;
c) at the time of transition to the next level of care, thus obtaining continued stay authorization for the next level of care; and
d) at time of discharge planning to ensure coordination of continuing care services in a seamless manner.
2. Communicates decisions and requests of third party payors and/or managed care organizations back to clinical staff, serving as liaison between the two.
3. Documents activities via computerized systems according to established timeframes
4. Maintains schedule of reviews and ensures all are conducted according to third party payor time frames
5. Monitors utilization of resources and lengths of stay for courtesy and scholarship patients.
6. Works closely with AR staff to ensure accurate benefits verification and financial planning for patient portion of bill, if applicable.
7. Monitors for trends in clinical care and notifies management staff as needed.
8. Works with and develops professional relationship and trust with provider/payor UR staffs.
9. Collects data and information for quality management activities as directed.
10. Documents pertinent clinical information into the electronic patient record.
11. Ensures that a welcoming, safe and healing environment is maintained for each patient and family throughout the continuum of care.
12. Recommends ways to improve the quality and delivery of services.
13. Maintains confidentiality of company and patient information.
14. Reacts productively to change.
15. Performs other duties as assigned.

SUPERVISORY RESPONSIBILITIES
None

QUALIFICATIONS:

An ideal candidate is an independent and curious self-starter with a demonstrated ability to produce high quality work in a fast-paced and ever-changing environment, along with a high tolerance for ambiguity and a bias toward action.  The requirements listed below are representative of the knowledge, skills and/or abilities required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE
LADAC, RN, or Bachelor’s degree in social work, psychology, or related field required with a minimum of one (1) year of behavioral healthcare experience with addiction treatment experience strongly preferred; UR and/or case management experience is strongly preferred; and/or equivalent education or experience in job related activities

OTHER SKILLS
Ability to speak, hear, see, sit, walk and stand; ability to speak, read and write in English; excellent customer service and interpersonal skills; excellent problem-solving and analytical skills; excellent written and oral communication skills; Microsoft Word and ability to learn and use clinical software and AS 400 accounting package; Excel preferred; ability to form collaborative relationships with third party payors; knowledge of and ability to apply information regarding cultural/age/population specific characteristics to patient care in assigned area. If recovering from addiction, one year of verifiable abstinence required with two preferred; active participation in appropriate 12-Step program preferred.

WORK ENVIRONMENT
Position is in an office setting that involves everyday risks or discomforts requiring normal safety precautions. Position involves long hours at desk and using head phone set. Position may involve contact with people in crisis, including those who are chemically impaired and/or volatile and may required additional safety precautions.