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Utilization Review Specialist
2 months ago
Embark Behavioral Health is seeking a highly skilled Utilization Review Specialist to join our team. As a key member of our Utilization Review Department, you will play a critical role in ensuring the smooth operation of our insurance authorization process.
Key Responsibilities- Work closely with the Utilization Review Supervisor to achieve departmental objectives and key performance indicators (KPIs).
- Ensure all potential clients receive necessary certifications for services to be rendered by collaborating with insurance companies, therapists, and the billing department.
- Develop and maintain effective communication with clients, families, and the billing department.
- Regularly communicate with treatment team providers to ensure seamless coordination of care.
- Monitor the fulfillment of all documentation requirements to ensure compliance with federal and state regulations.
- Conduct thorough research on denied claims and implement corrective action plans to resolve issues efficiently.
- Provide ongoing education to treatment team providers on documentation standards and best practices.
- Collect and analyze data to inform communication with insurance companies and other funding sources.
- Interface with managed care organizations, external reviews, and other payors to resolve authorization and payment issues.
- Complete pre-authorizations for Medicaid and other third-party payors as required.
- Submit retrospective review requests to insurance companies as necessary.
- Fulfill medical records requests for assigned caseloads.
- High School diploma or equivalent required; Associate's degree preferred.
- Customer service experience required; residential treatment experience preferred.
- Experience with insurance utilization review processes 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, including strong analytical skills.
- Strong professional communication skills.
- Skilled in negotiation and problem-solving.
- Patience and ability 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, and self-confident, with the ability to create systems for medical records and communication with Embark families in multiple programs.
- Comprehensive benefits package, including 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, 401(k) with company matching, and paid maternal leave.
- Company-paid holidays and a PTO accrual schedule.
- Embark Behavioral Health is an Equal Employment Opportunity Employer, committed to enriching the therapeutic and healing experience through the diversity of its employees and community.
