Become an Assembler! If you are looking for a company that is focused on being the best in the industry, love being challenged, and make a direct impact on our business, then look no further! We are adding to our motivated team that pride themselves on being client-focused, biased to action, improving together, and insistent on excellence and integrity.
We are looking for a Utilization Review Queue Specialist to join Acme Billing Solutions, an Assembly Health company. If you are looking for a company that is focused on being the best in the industry, love being challenged, and make a direct impact on our business, then look no further! This specific type of Utilization Review Specialist provides flexible, high-level support across the UR department by stepping in to manage cases when team members are out, experiencing high caseloads, or require additional assistance. This role demands exceptional adaptability, broad experience with behavioral health levels of care, and the ability to quickly onboard and complete reviews with accuracy and professionalism. The UR Queue Specialist ensures continuity of operations, maintains compliance with payer and regulatory requirements, and upholds our commitment to excellence by seamlessly absorbing and managing diverse UR responsibilities as departmental needs shift day to day.
This is a full-time, non-exempt position reporting to a UR Team Lead. The salary for this role starts at 60k
What You Will Do
- Serve as a flexible, highly adaptable UR resource by taking on overflow cases when team members are out (PTO, sick leave, etc), experiencing high volume, or require additional support to meet deadlines
- Evaluate patient medical records to determine the necessity and appropriateness of services provided.
- Quickly assess incoming overflow cases to identify urgency, payer requirements, and timelines, ensuring reviews are completed promptly and accurately.
- Analyze utilization data to identify trends, patterns, and opportunities for improvement, particularly as they relate to coverage gaps, bottlenecks, or queue needs.
- Communicate with behavioral health providers to obtain necessary information and clarify clinical details.
- Communicate with insurance companies to resolve coverage issues and denials.
- Collaborate closely with UR Team Leads and the broader UR team to ensure consistent application of protocols, guidelines, and payer-specific requirements across overflow cases
- Ensure that patient care meets regulatory requirements, accreditation standards, and payer requirements.
- Conduct timely reviews for each assigned queue case, maintaining productivity standards and meeting all deadlines.
- Stay updated on changes in regulations, standards, and guidelines affecting utilization review practices.
- Obtain prior authorizations for services as required by insurance companies and other payers.
- Monitor authorization periods for temporarily assigned cases and ensure timely renewals when your support is required.
- Maximize authorizations from insurance providers for all behavioral health levels of care through strong clinical documentation and communication.
- Maintain accurate, detailed, and organized records of reviews, decisions, communications, and case transitions back to primary UR staff.
- Identify and escalate issues that affect authorizations, providing clear documentation and communication to the primary UR Specialist and Team Lead.
- Prepare and submit required reports to management, payers, and regulatory agencies as needed.
- Review and appeal denied services as necessary, providing appropriate clinical information and documentation.
- Attends UR meetings to discuss activities/needs of UR department
- Execute additional duties as assigned, demonstrating diligence and meticulous attention to detail.
What it Takes to Join the Family
- Experience in healthcare, behavioral health (mental health, chemical dependency, or psychiatric nursing) preferred.
- Minimum of one year experience in utilization review.
- Comfortable working with common billing and EMR/EHR software
- Familiar with both inpatient and outpatient levels of care (MH and SUD)
- Knowledgeable of standard medical necessity criteria
- Adherence to strict confidentiality standards to safeguard patient care information and protect patient rights.
- Solid command of Microsoft Office applications, Google Suite, Adobe Acrobat, and other technologies
- Strong attention to detail and accuracy in data entry and financial records maintenance.
- Capability to manage multiple tasks and prioritize workload to meet deadlines.
- Keen Attention to Detail, Dependable, accountable, quick learner
- Exceptional interpersonal skills, organized, positive attitude, excellent verbal and written skills, excellent organizational skills, self-motivated and driven.
- Complies with all performance measuring regarding pre-certification, concurrent reviews, and appeals.
- Ability to function well in a fast-paced and at times stressful environment.
- Prolonged periods of sitting at a desk and working at a computer. Ability to lift and carry items weighing up to 10 pounds at times.
Why Assembly Health?
- Be part of something special! We are growing both organically and through acquisitions.
- Career growth - your next role with Assembly might not be created yet and we are waiting for your help to chart the way!
- Ongoing training and development programs.
- An environment that values transparency.
- Competitive Benefit Packages available, Paid Holidays, and Paid Time Off to enjoy your time away from the office.
Compensation for this role is based on a variety of factors, including but not limited to, skills, experience, qualifications, location, and applicable employment laws. The expected salary range for this position reflects these considerations and may vary accordingly. In addition to base pay, eligible employees may have the opportunity to participate in company bonus programs. We also offer a comprehensive benefits package, including medical, dental, vision, 401(k), paid time off, and more.
All official recruitment communications from Assembly Health will originate from an @assembly.health email address. Candidates are encouraged to carefully verify sender domains and remain vigilant against potential impersonation attempts. Communications from any other domain should be considered unauthorized.
