Clinical Utilization Review Specialist

Come join the team at WeCare!

WeCare is actively seeking a motivated Clinical Utilization Review Specialist in the Pittsburgh, PA area! This person will obtain authorization and complete admission process outlined below.

Job Description:

• The Regional Authorization Specialist will work closely with the Referral Director.

• Read/Familiarize the resident medical information to understand the key medical skilled needs for Nursing/Therapy services needed to obtain the appropriate authorization.

• Run Coverage Eligibility verification and upload into EHR.

• Obtain authorization (if applicable) - For HMO and Skilled Medicaid Authorizations by submitting appropriate medical documentation to Insurance Company requesting highest levels possible.

• Once Authorization obtained, collect all clinicals from referral links, hospital EHR, lateral host medical facility and upload into the EHR.

• Create/Add Resident onto the “Waiting List within EHR

• Create HMO Form and upload into HER.

• Add all resident specific demographics, medical professions, custom information, and extremal facilities within EHR.

• Add all payer information to the Resident Identifiers in EHR.

• Add the resident’s contacts. Ensure that if assigning the role of HCP/POA that paperwork is on file (uploaded into EHR).

• Send admission email to the specific email distribution groups timely and include attachments of specific pre-admission medical information and HMO form.

• Send Admission Agreement/Attachments to Resident/Representative via Carefeed.

• Audit/Review Carefeed Dashboard for outstanding Admission Agreements and Resident/Representative Contact Information.

• Update contact information after receiving signed Admission Agreement.

• Obtain MLTC Authorizations for Residents transitioning to LTC.

• Notify CM Team/Facility BOM when MLTC authorization obtained and NRD.

• Work with CM Team with any outstanding Authorization Issues.

• Other job duties as needed.

Shift:

Full – Time

Hybrid

Candidate Qualifications:

• Insurance experience in authorizations

• Understanding of admissions process

• Previous clinical experience

We reward hard working and caring professionals with competitive pay, benefits, and growth opportunities!

“The Journey Home Begins With WeCare”

The employment policy of WeCare is to provide equal opportunity to all persons. No employee or applicant for employment will be discriminated against because of race, color, religion, sex, national origin, age, disability, veteran status or any other Federal or State legally – protected classes.