Delphi Health Group

Utilization Review Specialist

US-FL-Ft. Lauderdale
2 weeks ago
ID
2017-1183
# of Openings
1
Category
Other

Overview

The Utilization Review Specialist is responsible for the reimbursement of treatment costs via insurance and managed care companies. Performs pre-certification reviews, concurrent reviews and will perform appeal reviews as needed. Provides appropriate client information to third party payers regarding medical necessity of treatment in a timely manner. UR Specialist will provide timely and accurate billing information to the billing company. Manages and updates the daily census and ensures its accuracy.

Responsibilities

  • Act as a liaison with insurance companies for reimbursement of treatment costs.
  • Analyzes insurance medical necessity criteria, governmental and accrediting agency standards to determine admissions, treatment, and length of stay.
  • Compares medical records to established criteria and confers medical, clinical and other professional staff to determine legitimacy of treatment and length of stay.
  • Analyzes and extracts pertinent clinical and medical information from medical records and reports information to insurance companies to acquire days of treatment.
  • Protects the confidentiality of patients and the privacy of staff.
  • Provide timely and accurate authorization information to the Utilization Review Director.
  • Displays communication skills.
  • Clear communication with UR Director and co-workers.
  • Maintain appropriate boundaries and ethical behavior with clients, families and other professionals.
  • Participate in staff meetings as needed.
  • Maintains documentation and files in an organized manner.
  • Other duties as assigned by Supervisor, CEO, COO, CFO or other management.
  • Willing and able to work weekends as needed to meet deadlines put in place by insurance companies.

Qualifications

  • Experience: 1 - 2 years’ related experience in behavioral health preferred
  • License and/or Certifications: MSW, LCSW, LMHC, LMFT, RN, LPN, BSN, Etc.
  • Skills:
    • Ability to work as a team member and have management, communication, organizational and interpersonal skills.
    • Knowledge of DCF guidelines.
    • Knowledge of State & Federal Statutes Regarding Patient Confidentiality Laws.
    • Knowledge of medical terminology.
    • Understanding of ASAM and Medical Necessity Criteria.
    • Basic computer skills

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