Utilization Review Clinician

Responsibilities

• Complete and manage all authorizations for designated programs & departments including prior authorization, continued stay, change in level of care, discharge, retrospective, facilitating peer to peer reviews, and written appeals.
• Engage in clinical rounds as an active treatment team member providing payor feedback and needs for next review, guidance on level of care recommendations, and feedback on what will be needed for authorization of clinically indicated services.
• Support treatment team members & Admissions by discussing services covered by the members benefits and reviewing clinical documentation needed to advocate with our client’s insurance most successfully.
• Communicate with billing regarding billing/claims issues and status of single case agreements as needed.
• Effectively communicate with program leadership, clinicians, and admissions regarding status of client authorization, potential denials, and potential for private payment.
• Follow workflow and medical record requirements for utilization review and clinical documentation across programs.
• Leverage understanding of medical necessity criteria and current behavioral health insurance landscape in verbal and written communications with payors to maximize our clients’ access to care and decrease peer to peer reviews.
• Communicate emerging trends with insurance companies to Director of Utilization Management.
• Maintain database of insurance company clinical care guidelines, APA guidelines, medical necessity criteria and other necessary documents and clinical ammunition to support UR process.
• Deliver care in a non-judgmental and non-discriminatory manner, sensitive to patient and staff diversity.
• Seek corrective criticism and evaluate suggestions objectively.
• Maintain acceptable overall attendance.
• Promote a favorable/positive work atmosphere.
• Attend in-services and educational training as necessary and as assigned.
• Seek out learning experiences and incorporate new knowledge into practice.
• Maintain flexibility and adaptability to expected and unexpected changes in the work environment.
• Report incidents, accidents, and occurrences in accordance with policies and procedures.
• Maintain safety of the physical environment.
• Comply with facility policies and procedures.

Qualifications

• Master’s Degree in Psychology, Social Work, Nursing, Nutrition, or mental health-related field required.
• At least one year of experience relating to insurance authorizations and managed care.
• Experience providing direct care to individuals with an eating disorder preferred.
• Licensed behavioral health clinician/provider or RD.