Utilization Review Specialist
Reports to: Utilization Review Director
Under the direction of the Utilization Review Director (URD), the Utilization Specialist acts as a
liaison with a patient’s insurance company, coordinates billing, payments, authorizations with
insurance companies, and monitors authorizations.
- High School Diploma/Equivalent
- Current CPR Certification
- Valid Driver’s License
- Proficiency in Microsoft Office Suite, including Word, Excel
- 5 years’ working experience or a minimum of Bachelor’s Degree in Social Work/Psychology or other related field
- 1 year experience working in a residential/behavioral healthcare setting.
- Experience working with insurance companies.
- Master’s level degree and licensure in social work.
JOB DUTIES AND RESPONSIBILITIES
- Act as an advocate and liaison with client’s insurance to coordinate authorization for
- Managing patient authorizations for treatment.
- Coordinate with clients, treatment team members and billing department routinely to
ensure timely and necessary communications to obtain authorizations and claims
payment from payers.
- Complete initial pre-cert requests with new admits as well as manage ongoing concurrent
reviews for continued authorizations from payers.
- Auditing and submitting requested medical records for claims
- Maintain all spreadsheets and data sources to track authorizations and data.
- Maintain organization and filing of all patient financial records.
- All other duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES
- Ability to communicate effectively both verbally and in writing.
- Computer literacy and proficiency in the use of Microsoft Office software.
- Knowledge of medical and behavioral health terminology
- Knowledge in reviewing medical and behavioral health records for medical necessity
- Skill in operating a personal computer and utilizing a variety of software applications,
printers and fax machine.
- Ability to apply UR Guidelines and processes consistently
- Knowledge of the current version of the Diagnostic Statistical Manual of Mental Disorders (DSM)