Utilization Review Specialist

Job Details

Description

Join a purpose-driven team at Caron Treatment Centers, where for nearly 70 years, we’ve been helping people find a path to recovery from addiction and rebuild their lives. We offer real careers with real opportunities for growth, comprehensive training, and a commitment to work-life balance. Our benefits include generous paid time off, company-paid life and disability insurance, professional growth and development, tuition reimbursement, a competitive 401(k) plan, and robust medical, dental, and vision plans. We’re proud to foster a diverse and inclusive environment, with a culture of teamwork, compassion, and dedication to our mission. Start a career that saves lives at a company that values yours!

Duties And Responsibilities

• The Utilization Review Specialist will complete initial pre-cert/concurrent and discharge reviews calls to managed care companies when needed for Caron inpatient programs.
• Provides Utilization review needs as determined with benefit verification (Verbal, written, faxed or access to managed care portals) as indicated.
• Fax ACT 106 prescriptions and/or required forms for treatment to manage care companies for authorizations with follow up documentation.
• The Utilization Review Specialist will complete medical records requests as it relates to authorization/discharge requests.
• Will complete appeal letters of medical necessity upon requests when needed.
• Documentation of accurate authorization or denial with reasons for the denials in the contact log.
• Complete all necessary documentation in Aura to produce an accurate claim at time of discharge for billing purposes and tracking of statistical reporting requirements.
• Will rotate weekend precertification coverage including holidays.
• The Specialist will uphold confidentiality and professionalism at all times.
• Will be point person for coordination of peer-to-peer reviews as identified for contracted insurances.
• Will ensure proper consent to release to insurance is accurate and reflected per the funding source
• Will ensure the medical level of care assessment is accurate and completed at time of admission.
• Will ensure documentation in the clinical record is up to date and reflective of the current level of care.
• This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the duties or tasks that may be required or assigned.
  
  

Physical Requirements

The physical and mental demands described here are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to communicate verbally for 85% of workday
• Ability to sit for 90% of workday
• Ability to type 85% of workday
  
  

Education / Experience Qualifications

• CAC or BA Human Services or Registered Nure or Licensed Practical nurse
• 1-year experience in customer service, in healthcare setting – required
• Computer experience –working knowledge of Microsoft Office (Outlook, Word and Excel) or similar software - required
• 2 years continuous sobriety preferred, if in recovery
  
  

Knowledge, Skills And Abilities

• Excellent verbal and written communication skills required
• Knowledge of addiction, 12 steps and ASAM level of placement criteria required
• Ability to report promptly and regularly to work
• Working knowledge of Microsoft Office
• Must demonstrate skills in achieving internal and external customer satisfaction.
• Will display an accurate understanding of the Treatment Planning Process, documentation and confidentiality regulations.
• Display an accurate understanding of medical necessity criteria, documentation and confidentiality regulations
• Ability to work as a member of a team and proactively identify needs of the department.
• Capable of working independently, coupled with the ability to discern the need for escalation and intervention