Utilization Review Specialist
Memorial Physician Practices, Georgetown, TX, United States
Job Description
Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine legitimacy of admission, treatment, and length of stay and interfaces with managed care organizations, external reviewers and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to managed care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.
Qualifications
Education: Bachelor's degree required. Master's degree preferred.
Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
License: Current unencumbered clinical license strongly preferred.
Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred. May be required to work flexible hours and overtime.
Job Responsibilities
Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services.
Completes pre and re-certifications for inpatient and outpatient services. Reports appropriate denial and authorization information to designated resource.
Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
Participates in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
Works with DON to ensure documentation requirements are met.
Ensures appeals are completed thoroughly and on a timely basis.
Interfaces with managed care organizations, external reviews, and other payers.
Communicates with physicians to schedule peer-to-peer reviews.
Accurately reports denials.
EEOC Statement
WellBridge Fort Worth is an Equal Opportunity Employer. WellBridge Fort Worth is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.
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Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine legitimacy of admission, treatment, and length of stay and interfaces with managed care organizations, external reviewers and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to managed care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.
Qualifications
Education: Bachelor's degree required. Master's degree preferred.
Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
License: Current unencumbered clinical license strongly preferred.
Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred. May be required to work flexible hours and overtime.
Job Responsibilities
Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services.
Completes pre and re-certifications for inpatient and outpatient services. Reports appropriate denial and authorization information to designated resource.
Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
Participates in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
Works with DON to ensure documentation requirements are met.
Ensures appeals are completed thoroughly and on a timely basis.
Interfaces with managed care organizations, external reviews, and other payers.
Communicates with physicians to schedule peer-to-peer reviews.
Accurately reports denials.
EEOC Statement
WellBridge Fort Worth is an Equal Opportunity Employer. WellBridge Fort Worth is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.
#J-18808-Ljbffr