What are the responsibilities and job description for the Utilization Review Specialist position at Sabino Recovery Group, LLC?
JOB SUMMARY:
The Utilization Review Specialist is responsible for ensuring the necessity and appropriateness of care, effective benefit management and coordination, as well as positive communications with patients/ residents and other parties as required.
ESSENTIAL JOB FUNCTIONS:
- Delivering daily census to billing.
- Responsible for providing and maintaining authorizations for treatment episodes.
- Maintain significant contact with referring healthcare professional associations, nursing service personnel, medical staff, patients/residents, families, insurance representatives, and billing and other staff.
- Reviews medical records to ensure proper utilization of treatment resources and quality of care for patients receiving behavioral health treatment.
- Complete cost/benefit analysis of treatment plans and negotiates appropriate rates.
- Assist the billing department in appealing denials through the payer’s appeal process.
- Understand the language of contracts and negotiates and/or renegotiates their terms, as necessary.
- Monitor the patient’s clinical progress as well as that of the treatment plan.
- Maintain daily contact with nursing units to identify patient needs related to diagnosis, treatment, prognosis, and projected date of discharge.
- Work with physician and treatment team to review orders regarding consults and discharge plans to ensure compliance with the patient’s insurance company.
- Prepare and maintain and daily census for billing, to include authorizations and denials.
