Utilization Review Specialist

The Next Door

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Job Summary

Mission: 

The Next Door provides a continuum of evidence-based substance abuse and mental health services for women in an environment of faith and healing to restore hope and a lifetime of recovery.

 

Summary:

Responsible for establishing and maintaining positive and effective communication with managed care companies. Aligns medical and counseling staff to ensure services are provided at the appropriate level of care in a timely manner consistent with the patient’s condition and in compliance with governmental and accrediting agencies.

Job Responsibilities

Primary Responsibilities and Duties include the following:

• Effectively manage pre-authorization, concurrent review and discharge communication with insurance companies in a timely manner.
• Conceptualize client cases and create clinical impressions to present to all Managed Care representatives.
• Collaborate, negotiate and advocate with managed care companies to ensure the best services to our clients.
• Collaborate with clinical team managers to ensure the services rendered are meeting expectations for quality of care and services.
• Analyze client records to determine legitimacy of admission, treatment, and length of stay in program.
• Interpret clinical documentation in preparation for concurrent request to extend the length of stay for client’s current level of care as appropriate.
• Advocate for the most appropriate number of days a client needs in each level of care based on clinical documentation. 
• Communicate necessary and appropriate information to insurance agencies.
• Communicate necessary and appropriate information to the clinical team and benefits and billing departments.
• Review clinical documentation to ensure it meets standards appropriate for insurance, licensure, state and accreditation.
• Maintain utilization review tracking system.
• Assist admissions staff with pre-certification as requested by supervisor.
• Attend weekly treatment team meetings.  
• Document appropriate information in agency’s EHR database and/or spreadsheets.
• Conduct weekly quality assurance audits.
• Provide staff coaching based upon quality assurance audit outcomes.
• Additional responsibilities as assigned.

Qualifications

Education and Experience:    

• Master’s Degree in Counseling,  Social Work, Nursing (RN, LPN) or related field required. 
• Current license, actively pursuing license or license-eligible in mental health or social  work is preferred. 
• Experience in utilization review required.
• Experience in Behavioral Health Care and knowledge of the ASAM criteria preferred.  
• Knowledge of Mental Health and Substance Abuse Disorders preferred. 

Other Requirements:

1. Possess proficient computer skills Outlook, Word, Excel, and PowerPoint
2. Valid Driver’s license
3. Personal Automobile Insurance, if applicable

 

All Employees will adhere to the following professional standards:

• Honor the agency mission:  The mission of The Next Door is to live out our faith by providing a continuum of evidence-based substance abuse and mental health services for women in an environment of faith and healing to restore hope and a lifetime of recovery.
• Consistently treat residents and co-workers with the utmost respect.
• Keep ALL information regarding staff, residents, diagnosis, group information, etc. confidential at all times.
• Work as a necessary part of the team effort.
• Model ethical and professional behavior at all times.
• Participate in ongoing meetings and trainings as required by the leadership of The Next Door.
• Be creative and assist leadership with ideas for improving the overall quality of the services and environment for the residents of The Next Door.
• Encourage and live the core values of The Next Door, Inc., at all times:

Additional Information

Benefits

How to Apply

Visit our website at www.thenextdoor.org and click on “About Us” and “Careers”.

Details

• Date Posted: June 23, 2020
• Type: Full-Time
• Job Function: Other
• Service Area: Social / Human Services