What are the responsibilities and job description for the Utilization Review Specialist position at Horizon Recovery?
Job Summary:
Horizon Recovery is seeking a detail-oriented and knowledgeable Utilization Review (UR) Specialist to join our team. The UR Specialist will be responsible for reviewing patient cases, coordinating with insurance providers, and ensuring that all services meet the necessary medical criteria for authorization and reimbursement. This role requires a strong understanding of commercial insurance processes, pre-authorizations, and utilization management within a behavioral health setting.
Key Responsibilities: Utilization Review and Case Management:
- Conduct Case Reviews: Review clinical documentation to ensure that services provided meet medical necessity criteria and align with insurance guidelines.
- Pre-Authorization Management: Submit and track pre-authorization requests for patient services, ensuring timely approvals from insurance providers.
- Concurrent Reviews: Monitor ongoing treatment plans, conducting concurrent reviews to secure continued authorization for services as needed.
- Collaboration: Work closely with clinical staff to gather necessary information and ensure accurate and complete documentation for UR purposes.
Insurance Coordination:
- Liaison Role: Serve as a point of contact between Horizon Recovery and commercial insurance providers, facilitating communication and addressing any issues that arise.
- SCA Support: Assist in the negotiation and management of Single Case Agreements (SCAs) under the direction of the UR Manager, ensuring all agreements are properly documented.
- Claims Support: Collaborate with the billing department to resolve issues related to insurance claims, including denials and discrepancies.
Documentation and Compliance:
- Accurate Record-Keeping: Maintain thorough and accurate records of all UR activities, including case reviews, authorizations, and communications with insurance providers.
- Compliance: Ensure that all UR processes adhere to state and federal regulations, as well as insurance provider requirements.
- Data Entry: Enter and update patient information in the electronic health record (EHR) system, ensuring data accuracy and completeness.
Problem-Solving and Appeals:
- Denial Management: Review denied claims, gather supporting documentation, and assist in the preparation of appeals to insurance providers.
- Problem Resolution: Identify and address any issues that may impact the authorization or reimbursement process, working proactively to resolve them.
Job Type: Full-time
Pay: $70,000.00 - $80,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Professional development assistance
- Referral program
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
People with a criminal record are encouraged to apply
Experience:
- Utilization review: 1 year (Required)
Work Location: Hybrid remote in Glendale, AZ 85308
Salary : $70,000 - $80,000