Utilization Review Specialist

About the role

The Utilization Review Specialist plays a pivotal role in ensuring the efficient and effective utilization of healthcare resources. They assist in reviewing and processing records to submit for authorization to the payors, collaborating closely with clinical teams, insurance providers, and other healthcare professionals to support efficient and effective patient care.

Responsibilities

• Review and analyze clinical records, including received documentation from payors, to ensure compliance with ABA therapy best practices and insurance requirements
• Accurately input and maintain clinical records, authorization requests, and related documents into the electronic health records (EHR) or other relevant systems
• Assist in tracking and organizing all documentation for utilization reviews, ensuring that all records are complete, accurate, and accessible for audits and reviews
• Maintain records of communications with insurance companies, clinical teams, and other relevant stakeholders
• Analyze trends in authorization requests, approvals, and denials and provide reports or insights to management to identify areas for process improvement
• Communicate effectively with team members to ensure the smooth processing of treatment authorizations and timely updates on status or concerns
• Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery

Requirements

• Associate's or Bachelor's degree in Healthcare Administration, Medical Records, Behavioral Health, or a related field
• Certification in Health Information Management (e.g., RHIA, RHIT) is a plus but not required
• Minimum of 1 year of experience working with clinical records, medical documentation, or utilization review, preferably in ABA therapy, behavioral health, or healthcare settings
• Proven experience in utilization reviews or a related field with a strong understanding of healthcare service delivery and documentation processes is highly desirable
• Must maintain clean background/drug screenings and driving record

Expertise Needed

• Familiarity with industry standards, guidelines, and best practices related to utilization review
• Strong critical thinking skills to assess the appropriateness and necessity of healthcare services
• Excellent communication and interpersonal skills

Benefits

• 21 paid days off (15 PTO days increasing with tenure, plus 6 paid holidays)
• Flexible Spending Account (FSA) and Health Savings Account (HSA) options
• Medical, dental, vision, long-term disability, life insurance, AD&D insurance, and GAP Plan (TransAmerica)
• Generous 401(k) with up to 6% employer match
• Tuition reimbursement up to $2,500 per semester
• EAP (unlimited counseling 24/7), BeyondMed (discounts on wellness and elective healthcare services), PerkSpot (discounts on top brands), Pet Insurance (Nationwide), and On the GoGa wellbeing hub