Utilization Review Coordinator Job at ShareHouse in Fargo

Salary: $65,000+ DOE

BENEFITS:

• Medical (Employee's Premiums 100% paid by company)
• Dental (Employee's Premiums 50% paid by company)
• Accident Insurance
• HSA and FSA/Dependent Care
• Critical Illness Insurance
• Vision Insurance
• Paid Short Term Disability
• Paid Group Life Insurance 
• Voluntary Life Insurance
• Voluntary Long-Term Disability
• Identity Protection
• Hospital Indemnity
• Generous PTO package
• 401k
• 401k matching
• EAP
• 9 Paid holidays

JOB SUMMARY

This position maximizes the quality and cost efficiency of clinical addiction services and ensures that patients receive the care they need, while identifying and ensuring appropriate and prompt payment by insurance providers and other third - party payors.

REPORTING RELATIONSHIPS

The Utilization Review Coordinator does not supervise any positions.

DUTIES & ESSENTIAL JOB FUNCTIONS

• Review client information prior to admission to determine insurance coverage and appropriate payment methods
• Review medical records, and confers with clinical and residential staff to validate medical necessity of treatment, length of stay for clients
• Gain approval from insurance provider and/or other third party payor to ensure coverage and timely/accurate receipt of payment
• Analyzes insurance governmental and accrediting agency standards to determine criteria concerning admissions, treatment and length of stay for residential clients
• Communicate with and follow up with insurance provider and/or other third party payor questions to provide all information necessary to facilitate prompt, accurate and timely payment of funds
• Verify client eligibility, as applicable, and past utilization history to ensure appropriate coverage and proper billing and payment
• Follow compliance rules and regulation for accurate billing of all levels of client care
• Interacts with third party payors, managed care organizations and gatekeeper organizations as appropriate on a case-by-case basis and maintains detailed documents of all interactions with representatives
• Designs, implements and evaluates the Utilization Review Plan and provides feedback and input on a regular, ongoing basis.
• Communicates relevant information to clinical staff, management and financial team regarding approved services and treatment, treatment denials, coordination of services, and/or appeals
• Manage workload to ensure timely processing per state and federal mandates
• Provide and maintain reliable and prompt attendance, with the ability to work the schedule dictated by business necessity

PERIODIC FUNCTIONS AND RESPONSIBILITIES

• Participate in special projects as needed and participate in team meetings
• Participate in Medication Quality Assurance Committee
• Assist clients in making informed decisions about their benefits and limitations of their health care coverage
• Assists in the development of policies and procedures, review policies and procedures periodically
• Maintains all confidential client information in files
• Other duties as assigned

QUALIFICATIONS

• Requires Bachelor’s degree in related field such as social work, nursing, counseling or human services; and
• Minimum of two years’ experience in utilization review, case management and medical record review
• Knowledge of ASAM criteria

REQUIRED LICENSES/CERTIFICATES

• Must possess one of the current licenses RN, LPC, LPCC, LAC, or LICSW. 

SKILLS, KNOWLEDGE AND ABILITIES

• Possess working familiarly with and knowledge of state and Federal regulations, company policies/procedures and insurance regulations that apply to chemical dependency treatment
• Knowledge of Medicaid, Medicare guidelines and covered services
• Demonstrate proficiency in Microsoft Office software, specifically Word and Excel
• Ability to read, analyze and interpret business communication
• Ability to clearly and effectively communicate and comprehend in both written and oral forms
• Possess high level of skill, tact and diplomacy with interpersonal relationship-building
• Ability to management multiple, competing tasks and demands and manage time efficiently
• Ability to handle crisis and emotionally-charged situations with poise and professionalism
• Ability to proof and check documents for accuracy
• Ability to use independent judgment in order to solve diverse and complex problems
• Ability to establish relationships with clients, peers, management and outside contacts
• Possess strong motivational , negotiation and influencing skills
• Ability to gain cooperation from others

PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job with or without reasonable accommodation:

Frequently requires:

• Use of color vision and ability to distinguish colors
• Stooping and bending
• Reaching and grasping
• Pushing and pulling, lifting and carrying up to 15 lbs
• Ability to communicate orally and hear/understand oral communication
• Ability to utilize fine motor skills, reach and grasp

Occasionally requires:

• Standing for up to 1 hour
• Pushing and pulling, lifting and carrying over 15 lbs

WORK ENVIRONMENT

This position frequently works in an environment with minor physical discomforts; may occasionally be exposed to drafts, noise, temperature variations, odors and similar conditions.  This position occasionally works in an environment that is uncomfortable and occasionally works with equipment or performs procedures where carelessness could result in minor injuries.