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Utilization Review Specialist II
Summary : This is a highly skilled position that requires an individual to work independently. This position requires the ability to determine clinical severity of illness/intensity of service criteria for individuals receiving care in any assigned level of care within the organization. A Care Management Specialist II exhibits excellent communication and documentation skills and works closely with insurers, accrediting bodies, and other healthcare providers. Clinical expertise regarding patient level of care needs is provided to other staff in consultation to ensure proper care in the right
amount, scope, and duration.
Duties and responsibilities:
● Maintain high level knowledge of behavioral health utilization review criteria and best practices including coordination of care with insurance companies, Medicaid and other payor sources.
● Familiarity with current provider manuals by insurer.
● Review with behavioral health companies updated clinical information on a timely basis for the purpose of utilization management certification, continued stay, and transition of care.
● Provide telephonic intake and crisis triage, verification of benefits, provide
accurate documentation, scheduling and level of care determination using
medical necessity guidelines.
● Oversee daily UR process at designated Recovery Works/Pinnacle
location(s) and take appropriate action when necessary. Close
communication with the facility treatment teams and accountability to inform
leadership of any issues pertaining to complete, accurate, timely
● Document all certification information received and advise Administration
Department of any insurance problems.
● Effectively input all authorization daily into the agency’s billing
software/database for applicable Recovery Works/Pinnacle location(s).
● Process appeals with managed care companies. Ensure documentation
submitted is complete, accurate, and timely.
● Participate in multidisciplinary team and Flash meetings for current clinical status and to maintain consistency in documented issues in the Electronic Medical Record. .
● Review hard copy authorizations for potential problems and notify appropriate Leadership.
● Assist in case management and transition of care duties as assigned.
Education and Experience Required:
● Master’s Degree in Social Work, Psychology, Counseling or related Human Services field is required.
● Licensed Clinical Social Worker (LCSW), Licensed Psychologist (LP), Licensed Professional Counselor (LPC), or Registered Nurse is required. Licensed Clinical Drug and Alcohol Counselor (LCADC) is preferred.
● Minimum of five years’ experience in the mental health and substance abuse field required; experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting preferred.
● Understand current DSM Diagnostic and ASAM Medical Necessity Criteria and demonstrate competence in making mental health and chemical dependency provisional diagnoses and level of care recommendations with available information.
● Knowledge and background with managed care and insurance preferred.
We are an Equal Opportunity Employer with a commitment to diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, disability or veteran status.