Address
Form of workJob Description
JOB SUMMARY:
The Utilization Review Representative position assists the Medusind team in Utilization Review. This position must demonstrate exceptional customer service skills with the ability to effectively communicate with internal and external customers. This position will assess clients to determine the appropriate Level of Care and will obtain authorization for a caseload of patients as well as potentially keeping client billing up to date.
The Utilization Review Representative position assists the Medusind team in Utilization Review. This position must demonstrate exceptional customer service skills with the ability to effectively communicate with internal and external customers. This position will assess clients to determine the appropriate Level of Care and will obtain authorization for a caseload of patients as well as potentially keeping client billing up to date.
DUTIES & JOB FUNCTIONS:
Utilization Review - The UR Representative is responsible for utilizing clinical information and knowledge of Medical Necessity criteria to effectively communicate plan of care to insurance case managers while conducting initial, concurrent, and discharge reviews to optimize benefits and reimbursements.
- Interfaces with clients to obtain necessary clinical documentation for reviews, outcomes and discharge planning.
- Communicates with insurance and managed care companies to inform them of diagnoses and health status of clients.
- Conducts doc-to-doc reviews and other appeals as needed.
- Reviews requested medical records for submission on a timely basis and follow up to make sure they are received.
- Knowledge of PAWS, carve-out plans, parity laws, and program modalities
- Client Confidentiality – UR Rep must maintain confidentiality of all pertinent patient care information to assure patient rights are protected.
- Other Duties as Assigned
Required Licenses/Certifications:
- High School Diploma/GED
- Experience working in Behavioral Health settings preferred
- A minimum of one-year experience working with the Utilization Review process
- Organized and detail-oriented
- Ability to manage time effectively and work with minimal supervision
- Demonstrates understanding of billing revenue codes CPT/HCPCS, diagnosis codes/ICD-10
SKILLS/SPECIAL REQUIREMENTS:
- Preferred but not required skills in: Detox, residential, PHP and IOP. Also, EMR experience such as KIPU, Zen Charts or lighting step. ASAM, MCG or LOCUS
- Must have knowledge of alcoholism, chemical dependency and co-occurring disorders.
- Demonstrate knowledge of State and Federal regulations, ASAM and AVA standards as they pertain to the job expectations.
- Possess the ability to make independent decisions when the circumstance warrants such action.
- Possess the ability to deal tactfully with personnel, clients, family members, visitors and the general public.
- Willingness to work harmoniously with other personnel.
- Possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
- Must have the ability to multitask in a dynamic (often fast-paced,) high-stress environment and prioritize tasks as necessary based on level of importance.
Physical Requirements/Work Environment:
- Walking, bending, and kneeling which will occur with moderate lifting of 30 or more pounds (suitcases, packages, supplies, etc.)
Salary: $21.00-$26.00 per hour
POSITION CLASSIFICATION:
Full-Time; Non Exempt
About Medusind Inc,:
Since 2002, organizations across the entire healthcare spectrum have leveraged our deep expertise and high-quality solutions to maximize revenue, reduce operating costs and navigate the changing healthcare landscape.Medusind’s unique combination of deep industry expertise, robust operational capability, and client-focused service significantly improves the efficiency and profitability of healthcare organizations. Client satisfaction is the primary focus of the Medusind leadership and staff.Our highly experienced personnel, cutting edge technology, and forward thinking approach allows us to deliver effective solutions while staying ahead of healthcare industry changes.
