Utilization Review Specialist

Description

We are looking for you! Do you want to be a part of the team that transforms lives? Cumberland Heights is more than a campus on 177 acres, it’s a community. Our mission is providing the highest quality care possible for persons and families who are at risk for or who are suffering from the disease of chemical dependency. Treatment encompasses the physical, mental, emotional, and spiritual dimensions of recovery by offering a safe, loving and healing environment, combining professional excellence and the principles of the Twelve Steps.

Cumberland Heights Foundation offers a comprehensive benefits program, which includes:

• Medical, Dental and Vision effective 1st day of month following 28 days of employment
• Employer Contribution for Health Saving Account or Health Reimbursement Account
• 401K with Company match and eligibility after 90 days of employment
• Paid Time Off (PTO) accrual beginning day (1) one and up to 20 days of PTO the first year
  
  

Position Summary

The Utilization Review Specialist is responsible for communicating pertinent information between the organization’s staff and various third party payors and managed care organizations in order to ensure maximum benefit from treatment services and the insurance benefits available.

PRIMARY DUTIES AND RESPONSIBILITIES include the some or all of the following:

• Processes clinical information from Cumberland Heights staff to third party payors and/or managed care reviewers
• at the time of impending admission to obtain initial authorization;
• at specified intervals during the patients’ treatment to report on progress and continued treatment needs, thus obtaining continued stay authorization;
• at the time of transition to the next level of care, thus obtaining continued stay authorization for the next level of care; and
• at time of discharge planning to ensure coordination of continuing care services in a seamless manner.
• Communicates decisions and requests of third party payors and/or managed care organizations back to clinical staff, serving as liaison between the two.
• Documents activities via computerized systems according to established timeframes
• Maintains schedule of reviews and ensures all are conducted according to third party payor time frames
• Monitors utilization of resources and lengths of stay for courtesy and scholarship patients.
• Works closely with AR staff to ensure accurate benefits verification and financial planning for patient portion of bill, if applicable.
• Monitors for trends in clinical care and notifies management staff as needed.
• Works with and develops professional relationship and trust with provider/payor UR staffs.
• Collects data and information for quality management activities as directed.
• Documents pertinent clinical information into the electronic patient record.
• Ensures that a welcoming, safe and healing environment is maintained for each patient and family throughout the continuum of care.
• Recommends ways to improve the quality and delivery of services.
• Maintains confidentiality of company and patient information.
• Reacts productively to change.
• Performs other duties as assigned.
  
  

Supervisory Responsibilities

None

Requirements

• LADAC, RN, or Bachelor’s degree in social work, psychology, or related field required.
• Minimum of one (1) year of behavioral healthcare experience with addiction treatment experience and/or UR and/or case management experience is strongly preferred.
• Intermediate computer skills including Microsoft Office Suite (Outlook, Work and Excel)
• Experience with AS400, accounting and/or medical software preferred.
• Ability to problem-solve, analyze, and interpret information.
• Excellent customer service skills and attention to detail.
• Ability to form collaborative relationships with third party payors.
• Ability to remain calm and supportive when dealing with hostile persons via phone.
• Ability to apply information regarding cultural/age/population specific characteristics to patient care in assigned area.
• Excellent written and oral communication skills with the ability to effectively speak, read and write in English.
• Ability to interact with co-workers in a collaborative and courteous manner.
• If recovering, one (1) year of verifiable abstinence required with active participation in a twelve-step program preferred.
  
  

WORK ENVIRONMENT

• Position is in an office setting that involves everyday risks or discomforts requiring normal safety precautions.
• Position requires frequent contact with people in crisis, including those who are emotionally volatile and may require additional safety precautions.
• Position involves long hours at desk and using head phone set.
• Ability to speak, hear, see, sit, walk, stand, reach, and use fine/gross motor skills.