What are the responsibilities and job description for the Quality Utilization Review Specialist position at Pride in North Carolina, LLC?
The Quality Utilization Review Specialist is responsible for evaluating mental and behavioral health services to ensure they are medically necessary, appropriate, and meet the established criteria for admission and continued stay. This role involves reviewing patient treatment plans, clinical documentation, and other relevant materials to assess the efficacy, appropriateness, and efficiency of the services being provided. The Specialist will ensure that mental health services are delivered in line with established standards, insurance guidelines, and best practices, while also ensuring cost-effectiveness in service delivery. The ideal candidate will have a strong understanding of NC Medicaid services, service definitions, Clinical Coverage policies, mental health diagnoses, treatment interventions, and clinical practices, as well as experience in utilization review processes within insurance or healthcare settings. The Quality Utilization Review Specialist will collaborate with clinical teams, providers, and insurance representatives to ensure that patients receive the right level of care at the right time.
Key Responsibilities:
- Review patient treatment plans, clinical documentation, and related materials to assess the medical necessity of mental and behavioral health services.
- Ensure services meet established criteria for admission and continued stay, in accordance with insurance and clinical guidelines.
- Collaborate with clinical providers to ensure that mental health services are appropriately aligned with patient needs and treatment goals.
- Analyze treatment outcomes and service delivery efficiency, recommending adjustments when necessary to ensure optimal patient care.
- Review and ensure that services comply with insurance reimbursement policies and other regulatory standards.
- Maintain detailed records of utilization reviews, including rationale for determinations and any recommendations for modifications in care.
- Provide feedback and recommendations to direct care providers to support appropriate care decisions.
- Stay current on the latest mental health treatment practices, clinical guidelines, and insurance policies related to behavioral health care.
Education/Experience/Skill Requirements:
- Preferably a licensed clinician (Licensed Psychologist, Licensed Psychological Associate, Licensed Clinical Social Worker, Licensed Clinical Social Worker Associate, Licensed Clinical Mental Health Counselor, Licensed Clinical Mental Health Counselor Associate, or Licensed Marriage and Family Therapist) who has at least one-year experience with the knowledge, skills, and abilities required by the population and age to be served.
- Strong understanding of mental and behavioral health conditions, treatment modalities, and clinical practices.
- Experience in utilization review, case management, or insurance oversight in a healthcare setting, preferably in mental and behavioral health.
- Knowledge of insurance criteria for behavioral health services and experience working with insurance providers.
- Excellent communication skills, with the ability to collaborate effectively with clinical teams, patients, and insurance representatives.
- Attention to detail and strong organizational skills for managing multiple cases and documentation.
Pride in North Carolina, LLC is an Equal Opportunity Employer
Benefits:
- 401(k)
- Dental insurance
- Employee assistance program
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Referral program
- Vision insurance
Pride in North Carolina, LLC (PRIDE) is committed to developing and promoting high quality residential and community services that provide nurturing, caring environments for adults and youth with special needs.This commitment is premised on the belief that all persons, regardless of the nature and extent of their disability, are capable of living, learning, and actively participating in their communities as productive and responsible citizens. Pride furthermore strives to maintain the dignity and worth of individuals and their families by acknowledging and respecting their needs, providing them with a support system, and working with them as equal partners. Within a spirit of collaboration and mutual respect, Pride emphasizes a partnership approach to service delivery, believing this is the most effective means of meeting the diverse treatment needs of the people we serve. Pride strives to serve as an innovative service delivery model to other public and private community agencies by actively enacting these values within the larger community.
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