The Utilization Review Specialist is responsible for managing all aspects of the utilization review process, including preauthorization, Single Case Agreements (SCA), continued authorizations, and collaboration with clinical staff to ensure documentation meets insurance requirements. This role is crucial in securing necessary authorizations for various levels of care, advocating for clients with insurance providers, and supporting the clinical team through training on medical necessity and documentation best practices. Work with outside agencies and third-party contractors as indicated or needed.
Job Duties:
Preauthorization:
- Manage and submit preauthorization requests to insurance providers for clients entering treatment at Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Standard Outpatient (OP) levels of care.
- Ensure all required documentation is complete and accurately reflects the clinical needs of the client.
- Communicate with insurance companies to secure timely approvals for necessary services.
Single Case Agreements (SCAs):
- Negotiate and manage Single Case Agreements with insurance providers for clients needing services outside of network coverage.
- Ensure that all SCAs are documented, approved, and communicated to the relevant clinical and billing teams.
Continued Authorizations:
- Monitor ongoing treatment needs and submit continued authorization requests for Residential, PHP, IOP, and OP levels of care to ensure uninterrupted client care.
- Work closely with clinical staff to gather necessary documentation, including progress notes and updated treatment plans, to support authorization requests.
- Track authorization deadlines and follow up proactively to prevent lapses in coverage.
- Collaborate with the clinical team to ensure a comprehensive understanding of each client when asking for continued authorization.
- Maximize the length of continued authorizations by using the comprehensive understanding of each client when presenting to insurance companies.
Clinical Staff Collaboration:
- Attend regular meetings with clinical staff to discuss client progress, treatment plans, and authorization needs.
- Provide feedback on documentation practices and suggest improvements to align with insurance requirements.
Training and Education:
- Develop and deliver training sessions for clinical staff on medical necessity criteria and documentation standards required by insurance providers.
- Create resources and guidelines for clinicians to reference when documenting client care and treatment progress.
- Offer ongoing support and education to ensure that all clinical documentation consistently meets the standards required for successful authorization.
Client Advocacy:
- Act as a liaison between clients, clinical teams, and insurance providers to advocate for the necessary care.
- Manage and appeal authorization denials, providing additional documentation or clarification as needed.
Compliance and Reporting:
- Ensure all utilization review activities comply with relevant regulations, insurance policies, and organizational standards.
- Maintain detailed records of all authorization requests, approvals, and communications with insurance providers.
- Generate reports on authorization success rates, SCA outcomes, and areas for improvement in the utilization review process.
Complete additional tasks as assigned or needed.
Minimum Qualifications:
- Education: Bachelor's degree in healthcare administration, social work, or a related field is preferred.
- Experience: At least 3-5 years of experience in utilization review, medical billing, or a related field, preferably in a behavioral health setting.
- Skills:
- Strong understanding of insurance authorization processes, including preauthorization, continued authorization, SCAs, and multiple levels of care.
- Excellent communication and negotiation skills with the ability to advocate effectively for client needs.
- Proficiency in electronic medical records (EMR) systems and documentation standards.
- Ability to collaborate with clinical staff and provide training on complex topics in a clear and supportive manner.
- Detail-oriented with strong organizational and time-management skills.
This is a full time role
Up to $6/hr
100% Remote Work
