Utilization Review Specialist

24 hours ago

Toronto, Ontario, Canada Embark Behavioral Health Full time
Overview

Embark Behavioral Health is seeking a highly skilled Utilization Review Clerk to join our team. As a Utilization Review Clerk, you will play a critical role in ensuring that our stakeholders receive the necessary certifications for services rendered.

Responsibilities
  • Work closely with the Utilization Review Supervisor to achieve departmental objectives and KPIs.
  • Ensure all potential clients receive appropriate certifications for services rendered by working closely with insurance companies, therapists, and the billing department.
  • Execute effective communication with clients/families and the billing department.
  • Communicate regularly with treatment team providers.
  • Monitor the fulfillment of all documentation requirements.
  • Make recommendations to define and improve quality of processes.
  • Monitor assigned facility data reports.
  • Research all denials with a forensic record review in a timely manner with a follow-up plan of correction.
  • Assist with ongoing education for treatment team providers regarding their role in maintaining documentation standards for all clients.
  • Collect information for communication with insurance or other funding sources.
  • Interface with managed care organizations, external reviews, and other payors.
  • Complete pre-authorizations to Medicaid and other third parties as required.
  • Submit retrospective review requests to insurance companies as required.
  • Fulfill all medical records requests to various individuals and entities on the assigned caseload.
Qualifications
  • High School/GED required, Associate degree preferred.
  • Customer Service experience required with residential treatment experience preferred.
  • Experience with insurance utilization review process and medical terminology; previous utilization review experience in a behavioral health or psychiatric healthcare facility preferred.
  • HIPAA Certification required upon employment.
  • Ability to maintain confidentiality in compliance with HIPAA Guidelines.
  • Familiarity with medical terminology, diagnostic terms, and treatment modalities.
  • Working knowledge of Windows-based applications, including Outlook, Word, and Excel.
  • Hands-on experience with accounting software and familiarity with MS Excel to include strong analytical skills.
  • Strong and professional communication skills.
  • Skilled in negotiation and problem-solving aptitude.
  • Patient and able to manage stress and maintain confidentiality.
  • Ability to apply state and federal laws, regulations, and policies governing utilization review.
  • Strong written and verbal communication skills.
  • Exceptional organizational skills and attention to detail.
  • Self-starter, self-sufficient, self-confident leading to an ability to create a system for medical records and communication with Embark families in multiple programs.
Benefits
  • Enjoy a comprehensive Benefits Program, encompassing medical insurance with a generous company contribution towards a high deductible plan, dental insurance, vision insurance, voluntary life and AD&D insurance, long-term disability, 401K with company matching, and paid maternal leave.
  • Revel in the balance of Company Paid Holidays and a PTO accrual schedule.
  • At Embark, we and our team members embody core values of empathy, trusting relationships, service, growth, and results. Join us in making a meaningful difference.

Embark is an Equal Employment Opportunity Employer. Embark is committed to enriching the therapeutic and healing experience it offers through the diversity of its employees and community. Embark seeks to recruit and support a broadly diverse staff who will contribute to the organization's excellence, diversity of viewpoints and experiences, and relevance in a global society.

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