Description
Clinical Utilization Review Specialist (Onsite position)
Lauderdale Lakes, FL
Growth Opportunity in Cutting-Edge Medical Billing
If you're an experienced clinician looking to forge a new career path where your clinical knowledge is valued, consider our Clinical Utilization Review Specialist position.
As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources. You will be responsible for reviewing and evaluating clinical documentation, treatment plans, and medical records to optimize patient care and streamline healthcare delivery processes. Ideal candidates will possess a clinical background, and preference will be given to individuals with specialized expertise, for example, BCBA (Board Certified Behavior Analyst), LSW (Licensed Social Worker), PT (Physical Therapist).
What You Will Do
Clinical Documentation Review :
- Evaluate and analyze medical records, treatment plans, and clinical documentation to ensure accuracy and compliance with established standards.
- Collaborate with healthcare providers to gather additional information or clarification on documentation when necessary.
- Live reviews with BSBAs and other health professionals
Utilization Review :
Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies.Identify and communicate potential issues related to overutilization or underutilization of services.Collaboration and Communication :
Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews.Communicate findings and recommendations clearly and effectively to internal teams and external stakeholders.Initiate, prepare and resolve appeals.Ensure EMR is up to date and accurate in regards to URAdvocate on the client(s) behalf to ensure services will be covered by insurance company.Work closely with clinical team to ensure continuity and quality of care for clientsComplete assessments, pre-certifications, initial authorizations, re-authorization, peer reviews and appeals.Ensure that all insurance information needed for billing and collection processes are obtained and recorded appropriately in the EMR system.Quality Improvement :
Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery.Provide feedback and suggestions for process improvements based on review findings.Regulatory Compliance :
Stay informed on relevant healthcare regulations, guidelines, and accreditation standards.Ensure compliance with all applicable laws and regulations in the utilization review process.Requirements
Education / Experience and Other Requirements
Bachelor's or Master's degree in Behavioral Health, Psychology, Social Work, or related field (or equivalent experience).Board Certified Behavior Analyst (BCBA) preferred.Additional certifications in Utilization Review or Quality Assurance are a plus.Minimum of 2-3 years of experience in Applied Behavior Analysis (ABA) therapy or related clinical field.Experience in utilization review, quality assurance, or case management is highly desirable.Expertise Needed
Strong understanding of ABA principles, clinical practices, and therapeutic techniques.Knowledge of insurance requirements, clinical documentation standards, and healthcare regulations.Excellent analytical, organizational, and problem-solving skills.Strong communication skills for interaction with clinical teams, families, and other stakeholders.Ability to adhere to HIPAA compliance standardsKnowledge and ability to communicate medical necessity using medical dialect.Knowledge in ABA guidelines and criteria to identify and advocate for appropriate care placement.
