Utilization Review Senior Specialist Job at Nextus Billing Solutions in Philadel

Job Summary

The Utilization Review Senior Specialist plays a crucial role in obtaining authorizations by performing a variety of functions which incudes, but not limited to, navigating electronic medical records and advocating for the patient; communicating with insurance carriers via phone/ fax as needed and articulating medical necessities using specialized language while strictly adhering to compliance standards.

Responsibilities and Duties

• Evaluate and prepare medical records to justify medical necessity
• Advocate on the client(s) behalf to ensure services will be covered by insurance company
• Ability to adhere to HIPPA compliance standards
• Ability to articulate medical necessity using medical dialect
• Proficient in personal time management, multi-tasking and calendar organization
• Complete new admissions and concurrent reviews in a timely manner
• Review clinical information and communicate documentation needs
• Establish and maintain professional relationships with care managers

Qualifications and Skills

• Proficiency with the utilization review process
• In-depth knowledge of the Substance Abuse Facility utilization review process and/or In-depth knowledge of Mental Health utilization review process
• Familiar with ASAM / and or medical necessity criteria for each level of care
• Effective communication skills, both verbal and written via phone and email
• Proficiency utilizing related software programs such as Kipu, ZenCharts, etc.
• Microsoft Office products including Word, Excel, and Power Point
• Knowledge in computers and can navigate various software programs

Education and Experience

• Experience conducting utilization reviews in healthcare setting
• Experience working in mental health or behavioral healthcare setting
• High-school diploma

(Preferred but not required):

• Bachelor’s degree or higher in Psychology or related field
• Licensed Mental Health Clinician (LCSW, LMHC, LMFT)
• Certified Addiction Counselor or Professional (CAC, CAP, MCAP, MAC)
• Experience working in a medical billing setting
• Experience working in Substance Abuse Treatment Industry
• Experience managing caseloads of 50+ per week
• Experience obtaining an average of 200 authorizations per month
• Knowledge in day-to-day operations of a psychiatric or behavioral healthcare setting
• Comprehensive knowledge of all levels of care (Detox, RTC, PHP, IOP, OP, Aftercare)