Utilization Review Records Analyst

Utilization Review Records Analyst – Exact Billing Solutions
Lauderdale Lakes, FL

Growth Opportunity in Medical Billing
Are you an experienced medical records professional ready to take your career to the next level with a growing, fast-moving company? You could be our Utilization Review Records Analyst, responsible for analyzing clinical records, communications, and therapy documentation to ensure compliance with regulatory standards, payor requirements, and best practices.

The UR Records Analyst will assist in reviewing and processing records to determine medical necessity, appropriateness, and the proper utilization of ABA (Applied Behavior Analysis) therapy services. This position collaborates closely with clinical teams, insurance providers, and other healthcare professionals to support efficient and effective patient care.

What You'll Do

Clinical Record Analysis

• Review and analyze clinical records, including received documentation from payors, to ensure compliance with ABA therapy best practices and insurance requirements.

Data Entry and Documentation

• Accurately input and maintain clinical records, authorization requests, and related documents into the electronic health records (EHR) or other relevant systems.
• Assist in tracking and organizing all documentation for utilization reviews, ensuring that all records are complete, accurate, and accessible for audits and reviews.
• Monitor the status of pending authorizations and document updates or changes to treatment plans in a timely manner.

Utilization Review Support

• Provide analytical support for the utilization review process by ensuring all relevant clinical documentation is included and up to date.
• Assist in processing and reviewing requests for treatment authorization, working with clinicians to verify that all necessary documentation is available for review.
• Collaborate with the utilization review team to ensure that therapy services provided meet the necessary criteria for approval.

Audit and Compliance

• Perform audits of clinical records to assess compliance with regulatory requirements, payer policies, and internal standards.
• Assist in preparing records and documentation for external audits or insurance company reviews, ensuring that all necessary information is submitted and compliant with guidelines.
• Identify any discrepancies, missing documentation, or areas where clinical records may require updates to meet the standards.

Insurance Liaison

• Assist in coordinating with insurance providers to obtain authorizations and resolve any issues related to service utilization or claims denials.
• Provide requested documentation and supporting materials for authorization and reauthorization requests, ensuring timely submission to insurance companies.
• Maintain records of communications with insurance companies, clinical teams, and other relevant stakeholders.

Trend Analysis and Reporting

• Analyze trends in authorization requests, approvals, and denials and provide reports or insights to management to identify areas for process improvement.
• Track utilization patterns, service delivery, and compliance with payer requirements to support continuous improvement in the utilization review process.
• Assist in compiling and generating regular utilization reports for review by management and clinical teams.

Quality Assurance and Improvement:

• Assist in ensuring that all clinical records and documentation are compliant with quality assurance standards and best practices for ABA therapy.
• Identify opportunities to improve the accuracy, completeness, and timeliness of clinical records and documentation related to utilization reviews.
• Support the development and implementation of best practices for record-keeping and documentation to streamline the UR process and ensure compliance.

Collaboration and Communication:

• Work closely with clinical staff, utilization review specialists, and other healthcare professionals to ensure that clinical records are properly prepared for review and meet necessary standards.
• Communicate effectively with team members to ensure the smooth processing of treatment authorizations and timely updates on status or concerns.
• Provide clear communication regarding the status of clinical record reviews, authorization requests, and insurance queries.