Utilization Review Nurse, Clinician or Specialist

Integrity Billing is a leading provider in the behavioral healthcare industry, known for our expertise, innovative technology, and commitment to ethical practices. We specialize in health information management, billing services, and revenue cycle management for behavioral health facilities. Our focus is on delivering exceptional service to help our clients manage their revenue cycle efficiently, ensuring streamlined operations and enhanced patient care.

We are seeking dedicated individuals to join our team and contribute to our mission of maximizing revenue and driving excellence in the behavioral healthcare sector. Experience the difference with Integrity Billing.

Job Summary

We are seeking a highly skilled Utilization Management Specialist to join our team. In this role, you will review medical records to assess the necessity and appropriateness of healthcare services. You will collaborate with healthcare providers and insurance payers, evaluate clinical criteria for service authorizations, and monitor patient care to ensure adherence to established guidelines.

Key responsibilities include staying informed on the latest policies, documenting cases accurately, and effectively communicating with both patients and healthcare teams to ensure smooth operations and compliance.

If you are detail-oriented, have strong communication skills, and are passionate about optimizing patient care, we would love to hear from you!

Duties

• Manage caseloads through the insurance process of initial authorization for admission, concurrent review, collaboration and consultation to obtain maximum reimbursement.
• Provide utilization review for all levels of behavioral health care, including inpatient, residential, partial hospitalization, intensive outpatient and outpatient authorization requests with contacts to facilities and providers as needed to accomplish this task.
• Negotiate with insurance companies to achieve the highest level of care for patients based upon ASAM and other approved criteria.
• Intervene concurrently on behalf of the patient / client by notifying facility points of contact with recommendations for continued treatment based on medical necessity or any issues that may have arisen during the most recent review.
• In collaboration with facility clinical team, specialists serve as a clinical resource to help formulate responses to denial of authorization for treatment and concerns issued by external agencies.
• Must be able to exhaust all levels of appeals in the event of a denied case and where necessary prepare and submit appeals and medical charts to payers.
• Provide on-call services for higher levels of care on a rotating on call schedule which may include holidays.

Qualifications

• High School Diploma or equivalent
• Licensure / Certification: LPN, RN, LCSW, LMHC preferred but not required.
• Knowledge and understanding or Utilization Review and Management and performance.
• Knowledge and understanding of medical, mental health, psychiatric and substance abuse diagnosis, treatments and clinical documentation.
• Knowledge and understanding of medical necessity criteria as it related to the American Association of Addiction Medicine (ASAM) and the dimensions and criteria for all levels of ASAM placement.
• Knowledge of computer programs.
• Ability to operate a computer and basic office equipment.
• Ability to operate a multi-line telephone system.
• Ability to read, understand and follow oral and written instructions.
• Ability to establish and maintain effective working relationships.
• Must be well organized and detail oriented.

(Preferred Qualifications):

• Knowledge of ASAM dimensions and DSM V
• Experience working within a medical billing or utilization review setting
• Experience working withing mental health or behavioral healthcare setting
• Experience utilizing related software programs such as Kipu, ZenCharts, Alleva, etc.
• Under guidance, develop the ability to manage a caseload of 20-30 cases weekly while obtaining 120 authorizations per month.
• Knowledge of the Substance Abuse Facility utilization review process

Ability to commute/relocate:

• Palm Springs, FL 33461: Reliably commute or planning to relocate before starting work (Required)

Job Type: Full-time

Pay: $50,000.00 - $70,000.00 per year

Benefits:

• 401(k) matching
• Disability insurance
• Life insurance
• Paid time off

Schedule:

• Day shift
• Monday to Friday
• On call

Ability to Commute:

• Palm Springs, FL 33461 (Required)

Ability to Relocate:

• Palm Springs, FL 33461: Relocate before starting work (Required)

Work Location: In person

Salary : $50,000 - $70,000