Utilization Review Specialist

The role

You will review patient care to make sure treatment and stays are medically necessary and cost-effective. You will work as a liaison between payers and the clinical care team, and prepare appeals on denied cases when appropriate.

What you will do

• Apply utilization criteria to monitor appropriateness of admissions, levels of care and continued stays
• Communicate with third-party payers for initial and concurrent clinical review
• Review patient charts to ensure the patient continues to meet medical necessity
• Document actions and information shared with care team members or payers
• Alert the clinical care team and management when a patient no longer meets medical necessity criteria for an inpatient stay
• Refer cases that exceed expected length of stay, expected cost, or show over or underutilization of resources to management
• Perform verbal or fax clinical review with payers as required
• Collect data on length of stay variances, lost days, discharge barriers and denied days
• Prepare appeals on denied cases when appropriate
• Maintain confidentiality and follow company policies and HIPAA guidelines

Required qualifications

• Master's degree in social sciences or commensurate experience
• Active substance abuse or mental health licensure in the state where treatment services are rendered, maintained for the entire employment
• 1+ year of experience in a relevant field
• Ability to exercise discretion and independent judgment and maintain professional boundaries and strict confidentiality
• Ability to apply clinical judgment, ethics and accountability to treatment plans and clinical documentation
• Strong personal boundaries and ability to build rapport with patients and staff
• Understanding of and adherence to the ethical standards of the licensure governing board
• In-depth knowledge of disease process, medical terminology, ASAM dimensions and utilization review
• Ability to communicate effectively with patients, families, payers and staff, verbally and in writing

Nice to have

• Excellent critical thinking skills
• Excellent organizational abilities
• Excellent communication skills, verbal and written
• Attention to detail and accuracy
• Comfortable analyzing information and dealing with complexity
• Ability to handle several tasks concurrently in a fast-paced environment
• Proficiency with Microsoft Office Suite

Benefits

• Subsidized health insurance for employee, spouse and dependents
• 100% employer-paid basic life insurance equal to 1x annual salary, up to $100,000
• 100% employer-paid employee assistance program
• Voluntary dental, vision, short-term disability, supplemental life and AD&D, critical illness, accident and hospital indemnity insurance
• Pre-tax savings accounts for IRS-allowable medical and dependent care expenses
• Generous paid time off plan
• Employee referral bonuses
• 401(k) retirement plan with employer match

Before you apply

• Must hold active state licensure and maintain it at hire and throughout employment

About the company

Northpoint Recovery Holdings, LLC is a behavioral healthcare provider offering treatment for adults with substance use and co-occurring disorders, and mental health treatment for adolescents. It operates seventeen facilities across the Western U.S. under an in-network, commercial insurance model.