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    UR (Utilization Review) Specialist - Denver, United States - Sunshine Behavioral Health

    Sunshine Behavioral Health
    Sunshine Behavioral Health Denver, United States

    4 weeks ago

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    Description
    UR (Utilization Review) Specialist

    Sunshine Behavioral Health is looking for a UR Specialist to join our motivated team. This position is fully remote. We offer Medical, Dental, Vision, 401k, and other worksite benefits, and a salary of $58,000 - $60,000

    Work schedule:
    Sunday - Thursday

    Duties

    Conducts timely; Precertification, Concurrent and Discharge reviews (Peer reviews and eligibility checks as necessary) as well as retro reviews and appeals as needed.

    Organizes and communicates information necessary to complete daily reviews. Clinical request should be sent to facility prior to 11am.

    Communicates necessary information with management and billing to ensure a seamless revenue cycle.

    Conducts audits of clients charts to ensure compliance with all payers, this includes monthly spot checks.

    Maintains up to date knowledge of insurance payer requirements.

    Keep current and accurate documentation in Salesforce and EMR systems.

    Performs precertification, prior approvals, and monitoring activities for mental health and substance abuse problems

    Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.

    Determines medical necessity and appropriateness of services using clinical review criteria based information given by providers.

    Accurately documents all review determinations and contacts providers and members according to established time frames.

    Identifies and refers cases that do not meet established clinical criteria to the clinical team leadership

    Performs accurate data entry in order to meet quality goals.

    Communicates information to other staff members as necessary/required.

    Participates in continuing education initiatives.

    Collaborates with Claims, Quality Management and Provider Relations as requested.

    Other duties as assigned.

    Qualifications


    Three (3) to five (5) years experience in chart analysis and utilization review in the psychiatric and chemical dependency filed preferred.

    Good oral and written communication skills required to communicate in a clear and concise manner with patients, physicians, staff, and administration.

    Stable emotional makeup required to work in a fast-paced environment with frequent interruptions.
    Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion.
    Strong work ethic built on a foundation of proactivity and teamwork.
    Ability to navigate ambiguity with the aid of structured problem-solving techniques.
    Computer proficiency in Microsoft Office

    Preferred Experience

    Degree in Psychology, Mental Health Counseling, Social Work or other related field. Bachelors Degree in Nursing.
    LSCW, LMHC or LMFT LMHC, or RN highly desired
    Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)


    Job Type:
    Full-time, remote

    Benefits:

    401(k)
    Dental insurance
    Health insurance
    Life insurance
    Paid time off
    Vision insurance

    Schedule:

    8 hour shift


    Education:
    High school or equivalent (Preferred)


    Experience:
    utilization review: 1 year (Preferred)
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