Utilization Review Specialist

3 weeks ago

Toronto, Ontario, Canada Embark Behavioral Health Full time

Overview

Utilization Review Representative

Pay: $20-$22 per hour

At Embark Behavioral Health, we are seeking a skilled Utilization Review Representative to serve as a liaison between our Utilization Review Department and stakeholders. The primary responsibility of this role is to ensure seamless communication and coordination with insurance companies, therapists, and billing departments to secure funds for our clients.

Responsibilities

  • Work closely with the Utilization Review Supervisor to achieve departmental objectives and KPIs.
  • Ensure all potential clients receive necessary certifications for services 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.
  • Monitor and fulfill all documentation requirements.
  • Make recommendations to improve quality processes and ensure compliance with federal and state regulations.
  • Research and resolve denials in a timely manner, implementing a follow-up plan of correction as needed.
  • Assist with ongoing education for treatment team providers on documentation standards.
  • Collect and provide information for communication with insurance or other funding sources.
  • Interface with managed care organizations, external reviews, and other payors.
  • Complete pre-authorizations and retrospective review requests as required.
  • Fulfill medical records requests for assigned caseloads.

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, including strong analytical skills.
  • Strong and professional communication skills.
  • Skilled in negotiation and problem-solving aptitude.
  • 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 a system for medical records and communication with Embark families in multiple programs.

Benefits

  • Enjoy a comprehensive benefits program, including medical insurance, 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 embody core values of empathy, trusting relationships, service, growth, and results, making a meaningful difference in the lives of our clients and team members.

Embark is an Equal Employment Opportunity Employer, committed to enriching the therapeutic and healing experience through the diversity of its employees and community.

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