Utilization Review Specialist

• Act as liaison between managed care organizations and the facility's professional clinical staff.
• Conduct interviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor the patient's length of stay and extensions and inform clinical and medical staff on issues that may impact the length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges, and quality of services, as required by the facility leadership team.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions and continued stay.
• Assist the Admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria, and medical necessity updates.

Education and Experience;

• Current State of Michigan, LLMSW, LMSW (Licensed Master's Social Work) or LLPC, or LPC (Licensed Professional Counselor).
• Previous experience in Utilization Management
• Two or more years of experience in a behavioral health setting

Education

• Bachelors or better

Skills

• Computer - Word
• Communication
• Oral Communication
• Attention to Detail
• Written Communication
• Problem Solving

Behaviors

• Team Player: Works well as a member of a group
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
• Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

• Self-Starter: Inspired to perform without outside help
• Goal Completion: Inspired to perform well by the completion of tasks

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)