The Next Door
Utilization Review Specialist
The Next Door
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:
- Possess proficient computer skills Outlook, Word, Excel, and PowerPoint
- Valid Driver’s license
- 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