UR Specialist

About Us: Our residential treatment program provides hope for clients suffering from mental health and substance use disorders, helping them ensure sustained recovery. Located in beautiful Deerfield Beach, Lifeskills provides a secure and nurturing atmosphere for balanced recovery and healing. 
Residential treatment program clients live in fully furnished townhomes that are professionally staffed 24-hours a day. This realistic, home-like setting allows residents to adapt their new coping skills within the local community and practice their daily routines while taking part in the therapeutic process. In our residential treatment program, we help our clients successfully transition back into their homes, family lives, and careers with newfound self-esteem, direction, and control.

Position Summary

Analyzes patient records to determine legitimacy of admission, treatment and length of stay in health care facility to comply with government and insurance company reimbursement policies.

Relationships and Contacts

Within the organization:  Initiates and maintains frequent and close working relationships with all other departments.

Outside the organization:  Maintains working relationships with insurance companies and their review process.

Position Responsibilities

1. Analyzes client records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies.
2. Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of clients.
3. Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
4. Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment.
5. Abstracts data from records and maintains statistics.
6. Determines patient review dates according to established diagnostic criteria.
7. May assist review committee in planning and holding federally mandated quality assurance reviews.
8. Communicates, both verbally and in writing, regarding all Utilization Review activity.
9. Triage incoming correspondence for the medical records requests/appeals, validating appeal criteria is met, or what medical records are needed to be submitted based on the request.
10. Compose technical denial arguments for reconsideration, including both written and telephonically.
11. Overcome objections that prevent payment of the claim and gain commitment for payment through concise and effective appeal argument.
12. Responsible for assigned appeal processing.  Able to pull medical records and review for appeals and create appeal package that will be sent to insurance company.
13. Utilize effective documentation standards that support a strong historical record of actions taken on the account.
14. Appropriately denotes claim of all activity initiated.
15. Participates in team meetings and discussions, contributing information regarding accounts receivable clean up as needed.
16. Maintains a strict level of confidentiality for all company, departmental, and healthcare provider information.
17. Reports challenges/ roadblocks to management for resolution.

Additional Responsibilities

1. Abides by all company policies and procedures.
2. Assisting with medical records for billing purposes as needed.
3. Assisting with prepayment reviews as needed
4. Understands the services provided by the company.
5. Consistently provides optimum Customer Service to all internal and external customers.
6. Performs other duties and projects as assigned.

ISJP123

Minimum Requirements

Bachelor's Degree (or equivalent experience) in Social Work, Mental Health Counseling, or related field. At least one year of work experience in the field of Mental Health and Chemical Dependency treatment in the Utilization Review department.

Physical Requirements

• While performing the duties of this job, the employee will be required to communicate with peers/general public, clients and/or vendors.
• Job performance will require the ability to move throughout the building as well as sit or remain stationary for extended periods of time.
• While performing the duties of this job, the employee may be required to talk or hear, sit, stand, walk, reach, climb or balance, stoop, kneel, crouch or crawl, taste or smell.
• Must be able to travel in and out of state to all facilities within the network of services, as necessary.
• Ability to move 25 pounds.

Skill Competencies

• Knowledge of major insurance companies, their policies and review policies.
• Excellent verbal and written communication.
• Ability to exercise sound judgment and discretion.
• Establish rapport with different departments.
• Excellent interpersonal and relationship building skills.
• Ability to prioritize and multi-task.
• Proficiency with Microsoft Office programs.

What We offer

• Multiple Development Pathways
• Company Supported Continuing Education & Certification
• PPO & HDHP Health Plan Options
• Flexible Dental & Vision Plan Options
• 100% Company Paid EAP Emotional Well-Being Support
• 100% Company Paid Critical Illness (with health enrollment plan)
• 100% Company Paid Life & ADD
• 401K with Company Match
• Company-Sponsored HSA, FSA, & DSA Tax Savings Accounts
• Six Annual Paid Holidays Plus One Floating Holiday
• Generous Team Member Referral Program

Lifeskills South Florida provides equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunity applies to all terms and conditions of employment. Aster Springs reserves the rights to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains "At-Will."