What are the responsibilities and job description for the Utilization Review Specialist position at KVC Health Systems?
Job Description
Job Description
Position Summary :
The Utilization Review department manages patient interactions with health plans, including initial, concurrent, and discharge reviews. This role involves frequent communication with health plans to share clinical information from the treatment team. The position requires attention to detail and accuracy in a fast-paced environment. As a key member of the treatment team, this role coordinates with admissions, physicians, nurses, and therapists to ensure timely and accurate assessments for patients and makes referrals for appropriate placement and services.
Education :
A Bachelor’s degree in a human services field (I.e., social work, education, sociology, psychology, counseling, applied behavioral sciences) or criminal justice preferred.
High school diploma or GED required
Experience :
A minimum of two years’ experience working in case management, utilization review, wellness coordination with at least one of those years of experience working with economically disadvantaged, vulnerable or at-risk youth and / or adults.
Preferred Experience / Skills :
Requires Intermediate skills in Microsoft Office Suite, including Word, Excel, and Outlook email. Strong interpersonal skills including oral and written communication
Certification / Licensure :
At least 21 years old
Valid Drivers License
Valid Auto Insurance
Job Duties / Responsibilities :
Engage in respectful and inclusive teamwork with all KVC departments and employees regardless of age, gender identity, sexual orientation, race, religion or ethnic background, and veteran status.
Work effectively with a wide range of constituencies, including but not limited to a multi-disciplinary internal team, external stakeholders, referral sources, other care providers, and insurance companies in a diverse community.
Ensure and monitor correct data is in electronic health records with authorizations / child specific contracts (single case agreements, etc.)
Assisting in mapping out contractual relationships, maintaining good relationships with these contracts and external agencies
Gathers data and compiles information completely and accurately and enter data into the data management systems
Conducts Utilization Review functions; reports to insurance companies; files appropriate forms and writes appeals for signature
Gathers and summarizes information for intake assessments and discharge summary reports
Maintains strictest confidentiality about child / youth / adult / family information
Assists in maintaining compliance with state, federal and The Joint Commission guidelines
Will assist with completion of paperwork for admissions and assist in other duties
Will assist with individual assignments such as audits of meaningful use data
Attends staff conferences and in-service training as required or needed
Provide reviews of documentation to enhance quality of records and ensure compliance with standards of care
Support special initiatives through quality assurance roles to enhance services for consumers
Other duties may be assigned
Join us :
We’re an equal opportunity employer committed to diversity and inclusion. We welcome applications from individuals of all backgrounds and experiences.
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