Utilization Review SpecialistAt — Newport Healthcare

The Utilization Review Specialist is responsible for managing an active caseload of clients at the following Levels of Care: Detox, Residential, Partial Hospitalization, and Intensive Outpatient. They act a liaison between insurance companies, the client, the client’s family, and the Clinical Team and are responsible for communicating updates to appropriate representatives at the insurance company, the Clinical Team, and the client’s family as directed by the Manager/Director of Utilization Review. They are responsible for gathering required information, effectively case-building, and collaborating consistently with members of both the Utilization Review Team and interdisciplinary Treatment Team to ensure optimization of each client’s coverage and benefits.

Essential Duties:

• Coordinate, schedule, and complete Initial, concurrent, Peer, and retrospective reviews in a timely manner to ensure continuous coverage, per use of clinical information and knowledge of Medical Necessity criteria, to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.
• \u202aConduct and manage initial, concurrent, and discharge reviews to optimize benefits and utilization while representing the UR Department in a professional and positive way to other Departments and the company as a whole.
• Maintain contact with the clients’ families and keep them updated on current insurance authorization updates, Peer Reviews, and Denials.
• Document all activities in a detailed manner in applicable CRM/EMR.
• \u202aCollaborate with Clinicians and the multidisciplinary team daily at both the Residential and Day Programs in order to obtain necessary clinical documentation for reviews and ensure effective utilization of resources.
• \u202aParticipate in weekly Treatment Team and Continuing Care Meetings as appropriate.
• \u202aPrepare and submit Appeal documentation (including rationales) to the appropriate entities as indicated.
• Complete weekly Treatment Team notes and provide updates to the Psychiatrist as requested by the Director/Manager.
• Follow chain of command both within the Department and outside of the Department.

Qualifications

• At least two (2) years of work experience in the behavioral health field.
• Active license or credential in a behavioral health field preferred.
• Bachelor’s or Master’s in a behavioral health related specialty preferred.

- Completing insurance reviews daily
- Collaborating with treatment team weekly in meetings
- Scheduling and completing peer reviews / appeals
- Weekly chart audits
- QAPI

Training:

- Weekly 1:1 w/ supervisor
- Weekly treatment teams
- Biweekly all staff meetings

Learning Outcomes:

- Understand medical necessity criteria (CALOCUS, Interqual, ASAM)
- Understand the peer review and appeal process
- Understand external appeals, such as DMHC