The Next Door
Utilization Review Specialist
The Next Door
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.
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.
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.
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.
- 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:
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”.
- Date Posted: June 23, 2020
- Type: Full-Time
- Job Function: Other
- Service Area: Social / Human Services