[Hiring] Utilization Review Specialist @ADDICTION AND MENTAL HEALTH SERVICES, LLC

Role Description

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.
• Maintaining compliance with healthcare regulations.
• Working closely with insurance companies, clinicians, and support staff.
• Advocating for the best interests of the patients and the hospital.

Key Responsibilities
• Case Review and Assessment:
• Conduct daily reviews of patient charts, treatment plans, and progress notes to determine alignment 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.
• 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.
• 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.
• 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.
• 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
• Bachelor’s degree in Nursing, Social Work, or a related field required.
• Master’s degree in a health-related field preferred.
• Minimum of 2 years in utilization review, case management, or related field, preferably within a behavioral health or chemical dependency setting.
• Current RN, LCSW, or LPC license preferred.
• 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.

Benefits
• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
• Student Loan Repayment – Available for nurses and therapists.
• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
• Generous PTO – A robust paid time off policy to support work-life balance.
• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.