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The Next Door

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

The Next Door offers employer-paid health insurance for employees, Employee Assistance Program, PTO, and 401K participation.

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