Utilization Review Specialist
About the Role
New Horizons is the largest mental health and addiction recovery provider on the Treasure Coast (and beyond), serving 15,000 children and adults annually through inpatient crisis services, a 24-hour help line and mobile response team, and outpatient programs conveniently located across Indian River, Martin, Okeechobee, and St. Lucie counties. We also assist 22,000 students in area schools and collaborate closely with courts, law enforcement, jails, and hospitals to improve individual health and community quality of life.
This is a hybrid role responsible for following up on patient accounts when authorization for stay is required, initiating pre-certification via telephone or provider portal, reviewing patient medical records via EMR to ensure criteria for the appropriate level of care are met, and providing clinical information to insurance companies to obtain authorization.
Responsibilities
- Follow each account during the inpatient stay and at discharge for authorization, documenting status in the electronic system.
- Escalate any potential disputes or denials of accounts to the Director of Revenue or designee.
- Track disputed claims by payor.
- Obtain and follow authorization for Case Management Services.
- Adhere to federal, state, payer, and local regulations and accreditation requirements impacting case management scope of services.
- Comply with department structure, staffing, policies, and procedures to meet CMS Conditions of Participation and agency policies.
Requirements
- High School diploma or equivalent (required).
- Organizational skills, verbal and written communication skills, problem-solving skills, and computer literacy (required).
Qualifications
- Associate or Bachelor’s degree (preferred).
- Paramedic, EMT, or Nursing Assistant certification (preferred).
- Acute hospital experience (preferred).
- Data analytic skills (preferred).