What are the responsibilities and job description for the Utilization Management Specialist position at Key Recovery and Life Skills Center?
Job Summary:
Under the direct supervision of the Clinical Director, the Utilization Management (UM) Specialist is responsible for ensuring patient eligibility, authorization of services based on medical necessity, and contractual and regulatory medical necessity standards. The UM Specialist monitors reports on denials and responds to difficulties with health service approvals at all service levels. Works closely with designated clinical staff to coordinate submission of patient information within health plan timelines. The UM Specialist is also responsible for reviewing assessments and collateral documentation for applicants and coordinating admission dates for applicants that meet program criteria with referring agencies.
Essential Duties and Responsibilities:
Apply American Society of Addiction Medicine (ASAM) Patient Placement Criteria and other utilization review criteria, as outlined in health plan provider manuals, to client authorizations and concurrent reviews.
Request peer to peer reviews and appeals and collaborate with the Clinical Director to provide supporting documentation.
Review assessments from referral agencies and gather any information necessary to determine if the applicant is a good fit for the requested program.
Review any individual who does not meet admission criteria with the Clinical Director.
Monitor client census and ensure adequate numbers are maintained and communicate with prospective clients and/or referring agencies to coordinate appropriate bed dates.
Participate in health plan and State or federal training in eligibility as assigned.
Review and advise Clinical Director promptly on issues related to client access to care; seek guidance on problems from supervisor.
Maintain collaborative relationships with the Clinical Director and clinicians.
Report to supervisor and management on results of UM as well as trends in problems.
Maintain a record keeping system to ensure that applications and authorizations are obtained within established timelines.
At the direction of the Privacy Officer, disclose records in accordance with the request provided.
Other duties as assigned.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Education/Experience:
Must have an associate degree in behavioral health, addiction studies or similar field
Bachelor's degree in a related field (e.g., behavioral health, social work, psychology) preferred
2 years of experience in utilization review or a related field
Certification and experience working as a SUDP preferred
What We Offer:
Well compensated workforce in a positive, friendly, team-oriented environment!
Compassionate, caring coworkers and administration committed to making a difference for our patients (and our staff)!
Generous benefit package with company-paid medical, dental, vision, life insurance, retirement plan with employer match, and flexible hours.
Opportunities for advancement.
Paid sick and vacation leave plus 10 paid holidays.
About Key Recovery and Life Skills Center
Key Recovery and Life Skills Center is an inclusive and safe space offering hope and healing to ALL individuals with substance use disorder. Our skilled and credentialed staff focus on trauma-informed, evidence- and strength-based practices that treat the whole person and family.
