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- 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 client's 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.
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UR (Utilization Review) Specialist - Denver, United States - Sunshine Behavioral Health
Description
UR (Utilization Review) SpecialistSunshine 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
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. Bachelor's 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)
UR (Utilization Review) Specialist professionals in Denver
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Nicole Stephens
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Haley Pierce
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