Utilization Review Specialist Job at Triumph Treatment Services in Yakima

"Ensuring Safety Excellence: In compliance with Washington State's ESSB 5123, we prioritize safety in our workforce by conducting controlled substance testing, including marijuana, for this position, which is deemed safety-sensitive.”

Position Summary:

The Utilization Review Specialist will promptly submit clear and timely utilization reviews to payers to secure payment for clients undergoing treatment at Triumph’s five residential facilities. This will be achieved by assessing medical necessity in collaboration with the multidisciplinary team, precisely applying ASAM criteria, and proficiently communicating the requirement for continued stay to the appropriate managed care organization (MCO).

CORE COMPETENCIES

Collaborates with Others

Collaborating cohesively and in a helpful manner to accomplish shared objectives alongside peers.

• Recognizes and honors the contributions and hard work of others.
• Offers valuable and actionable feedback to peers in a constructive and professional manner.

Acting with Empathy and Compassion

Genuinely understand and respect for others' perspectives and emotions. Strive to foster a culture of compassion, empathy, and support that extends beyond our walls.

• Maintains open and effective communication channels with team members.
• Stays open, curious, and flexible to suspend judgments and evaluations when considering what others offer.

RESPONSIBLITIES

• Uphold and apply an in-depth understanding of ASAM and WAC criteria across various levels and facets of treatment requirements.
• Foster and maintain collaborative relationships with both internal and external partners involved in client case management.
• Review client enrollment data and clinical documentation to ensure compliance with federal, state, and contractual regulations relating to medical necessity and case documentation.
• Monitor and communicate residential authorization periods and requirements to residential clinical teams for discharge planning.
• Employ strong written and verbal communication abilities to advocate for clients in securing insurance coverage for necessary services.
• Collaborate with clinical supervisors to ensure accurate documentation of client medical records, reflecting their progress towards treatment goals and ongoing needs. Additionally, provide training to clinical team members to enhance documentation skills as needed.
• Communicate with clinicians to rectify errors or omissions and investigate questionable claims.
• Conduct audits and analysis of client records to ensure the provision of quality care and appropriateness of services.
• Assess clinical documentation for denied days or admissions against criteria to determine suitability for requested treatment.
• Uphold an effective, positive customer service demeanor towards clients, their families, and colleagues, while remaining attentive to client needs.
• Other duties as assigned.

QUALIFICATIONS AND REQUIREMENTS

Education:

Experience:

Licenses/Certificates/Registration:

WORKING CONDITIONS

1. Comprehension
   1. Ability to understand, remember, and apply oral and written instructions or other information.
2. Reasoning and Decision Making
   1. Ability to plan, organize, and carry out assignments from management staff with minimal direction.
   2. Ability to analyze situations and make decisions that moderately impact the immediate work unit.
3. Organization
   1. Ability to organize and prioritize job duties effectively and timely, set priorities, and meet critical deadlines.
4. Communication
   1. Ability to understand and follow basic instructions and guidelines, complete routine forms, and communicate orally.
5. Physical requirements for this position include hearing, seeing, smelling, speaking, feeling, reaching, pinching, and repetitive motions.
   1. This position requires standing, walking, and bending for long periods.
   2. This position may require exerting up to 40 pounds of force to lift, carry, pull, or move objects

Triumph Treatment Services complies with federal and state laws and applicable discrimination regulations based on any protected class as defined by law. Triumph Treatment Services specifically does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, honorably discharged veteran or military status, sexual orientation including gender expression or identity, non-job related sensory, mental or physical disability, or the use of a trained guide dog or service animal by a person with a disability. This holds for all employment opportunities at Triumph Treatment Services.