UR Specialist

The Utilization Review Specialist will be providing first level initial admission and continued stay case reviews. The right candidate will assist in determining the appropriate cases for review by utilizing both client specific guidelines and clinical experience in collaboration with the medical and admissions team. Candidate will need to rely on utilizing clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. This is achieved by applying the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. The right candidate communicates with providers to facilitate care/treatment.

Responsibilities:

• Assess member’s needs
• Performs inpatient utilization review and applies client guidelines as detailed in the client UM Plan for length of stay/admission criteria to approve initial and continued inpatient services.
• Identify solutions to problems and non-standard requests
• Conducts UM review and discharge planning at the facility level
• Follows and maintains compliance with regulatory agency requirements
• Maintain courteous, professional attitude
• Collaborate with staff, physicians, medical team, admission coordinators, members and their families to coordinate and provide the level of care necessary to meet member’s need.
• Ensure that appropriate clinical documentation is in place
• Abstract data from a variety of medical records to ensure accurate clinical data
• Participates in treatment team meetings and clinical pass on.
• Generating Appeals to support client care and assist billing office with claims payments.

Requirements:

• Ensure effective communication skills, both verbal and written. Effectively communicates in a timely manner to management and internal departments. Providing Internally/externally excellent customer service.
• Proficient in MS Office Applications and ability to learn department and job specific software systems. Position requires proficiency with computer skills which includes navigating multiple systems
• Perform other duties as assigned by departmental leadership in support of departmental and organizational strategies and goals which may include: system testing, training and other opportunities that promote growth
• Complete and maintain annual compliance and annual HIPAA training
• In-depth knowledge of current standard of medical practices and insurance benefit structures.
• Knowledge and competency in all types of medical-necessity decisions, including inpatient care, sub-acute and outpatient care.

Compensation for roles at Azure Acres varies depending on a wide array of factors including but not limited to the specific location, role, skill set, and level of experience. As required by local law, Azure Acres provides a reasonable hourly range of compensation for roles that may be hired in California set forth below.

Role Location: Sebastopol, California

Calculated Hourly Range for role: California: $26.00 – $31.00 per hour

• Participate in organizational educational offerings and required training as needed to support service delivery.
• Excellent analytical-thinking/problem-solving skills.
• The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads with the ability to switch priorities in a positive and effective manner when directed by leadership with the ability to work independently with limited supervision.
• The ability to offer positive customer service to every internal and external customer, including challenging personalities.
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.

Compensation for roles at Azure Acres varies depending on a wide array of factors including but not limited to the specific location, role, skill set, and level of experience. As required by local law, Azure Acres provides a reasonable hourly range of compensation for roles that may be hired in California set forth below.

Role Location: Sebastopol, California

Calculated Hourly Range for role: California: $26.00 – $31.00 per hour

Skills

• Written Communication
• Typing
• Problem Solving
• Safety Minded
• Planning & Organizing
• Oral Communication
• Negotiating
• Customer Focus
• Computer - Word
• Computer - Excel
• Communication
• Attention to Detail

Behaviors

• Team Player: Works well as a member of a group
• Thought Provoking: Capable of making others think deeply on a subject
• Innovative: Consistently introduces new ideas and demonstrates original thinking
• Enthusiastic: Shows intense and eager enjoyment and interest
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
• Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

• Work-Life Balance: Inspired to perform well by having ample time to pursue work and interests outside of work
• Self-Starter: Inspired to perform without outside help
• Peer Recognition: Inspired to perform well by the praise of coworkers
• Job Security: Inspired to perform well by the knowledge that your job is safe
• Growth Opportunities: Inspired to perform well by the chance to take on more responsibility
• Goal Completion: Inspired to perform well by the completion of tasks
• Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals
• Financial: Inspired to perform well by monetary reimbursement
• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)