Utilization Review Specialist

Location: Remote, Monday-Friday 8am-5pm MSTFull-TimeJunior

Salary30 - 35 USD per hour

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Job Details

Have a Master’s Degree of Social Sciences or commensurate experience.
Hold an active substance abuse or mental health license in the state where treatment services are rendered.
Maintain applicable state licensure requirements at hire and throughout employment.
Have at least 1 year of experience in a relevant field.
Apply clinical judgment, ethics, and accountability to formulate and implement treatment plans and clinical documentation.
Understand disease processes, medical terminology, ASAM dimensions, and utilization review.
Have exposure to nationally recognized criteria used to determine medical necessity.
Exercise discretion and independent judgment, maintain professional boundaries, and protect confidential client information.
Understand and adhere to the ethical standards of the applicable licensure governing board.
Use Microsoft Office Suite.

Apply utilization criteria to review admissions, associated levels of care, and continued stays.
Communicate with third-party payers for initial and concurrent clinical reviews.
Review patient charts to determine whether patients continue to meet medical necessity.
Document actions and information shared with care team members or third-party payers.
Discuss cases with the clinical care team and management when patients no longer meet inpatient medical necessity criteria.
Refer cases to management when they exceed expected length of stay or cost, or involve over- or underutilization of resources.
Perform verbal or fax clinical reviews with payers as appropriate.
Collect data on length-of-stay variances, lost days, costs, discharge or transition barriers, and denied days.
Prepare appeals for denied cases when appropriate.

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