Utilization Review Specialist
New
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Northpoint Recovery Holdings, LLCBehavioral healthcare
Location: Remote, Monday-Friday 8am-5pm MSTFull-TimeJunior
Salary30 - 35 USD per hour
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Job Details
- Experience
- 1+ year of experience in relevant field required
- Required Skills
- Microsoft Office Suite
Requirements
- Hold a master’s degree in social sciences or have commensurate experience.
- Hold an active substance abuse or mental health license in the state where treatment services are rendered.
- Maintain applicable state licensure requirements throughout employment.
- Have at least one year of experience in a relevant field.
- Use 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 experience with nationally recognized criteria for determining medical necessity.
- Exercise discretion and independent judgment, maintain professional boundaries, and protect confidential client information.
- Understand and follow the ethical standards of the applicable licensure governing board.
- Demonstrate proficiency with Microsoft Office Suite.
Responsibilities
- Apply utilization criteria to assess admissions, levels of care, and continued stays.
- Conduct initial and concurrent clinical reviews with third-party payers.
- Review patient charts to confirm continued medical necessity.
- Document actions and information shared with care team members and payers.
- Alert clinical teams and management when a patient no longer meets inpatient medical necessity criteria.
- Refer cases exceeding expected length of stay or cost, or involving resource over- or underutilization, to management.
- Conduct verbal or fax clinical reviews as appropriate.
- Collect data on length-of-stay variances, lost days, costs, discharge barriers, and denied days.
- Prepare appeals for denied cases when appropriate.
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