Utilization Review Specialist

SERV, a well-established leader in behavioral healthcare in New Jersey, supports people with mental illness and/or intellectual/developmental disabilities as they achieve greater independence and life satisfaction through a wide range of services.

The Utilization Review (UR) Specialist reports to the Access to Care Department within the revenue team. This position is responsible for contacting external case managers and managed care organizations for pre-authorization and concurrent reviews throughout the duration of a consumer’s stay. The Specialist assists the treatment planning team in understanding insurance requirements, and completes UR audits for billing compliance.

Responsibilities

• Reviews consumer records to ensure proper utilization of treatment resources; reviews records for proper documentation and necessity of treatment under applicable regulations to determine which clinical documentation is appropriate to provide to the MCO’s.
• Interpret the consumers’ level of care and if they are an imminent risk to themselves or others.
• Review the assessments completed by the program nurses and provide the MCOs with all pertinent information related to any medical and mental health diagnoses.
• Provide justification as to why the consumer needs continued stay and provide treatment goals and plans for level changes.
• Update consumers’ progress and discharge planning.
• Provide updates on consumers’ current mental health status.
• Possess a basic understanding of medications and provide names and dosage information to the MCO (verbally and/or electronically).
• Justify consumers stay by speaking with MCO’s medical doctor for authorizations that require a second level review.
• Determine which Procedure code and Modifier should be used based on consumers’ level of care.
• Have a general understanding of clinical terminology as it relates to mental and medical health.
• Determine the number of requested units depending on the consumers’ length of stay and level of care.
• Understand differences in Partial care unit requests, including but not limited to, calculation differences, routing difference, and workflows for routing assessments to Nurse Practitioners vs. Registered Nurses and Physician review.
• Establishes and maintains contact with managed care organizations.
• Establishes contact with insurance and managed care companies and verifies treatment benefits.
• Collects and records all information necessary for admission and extended stay.
• Conducts random continuing-stay reviews to ensure consumers in treatment require and are benefiting from the services they are receiving.
• Interfaces with other departments in matters of review decisions, discharge planning and fiscal communication.
• Notifies psychiatrists and other clinical staff of the need for pre-certification and clinical reviews;
• Assists the treatment planning team in understanding insurance requirements for admission, continued stay, and discharge planning.
• Reviews over- and under- utilization data with leadership.
• Completes UR audits to ensure compliance for billing purposes.
• Develops UR reports and statistics.
• Attends and participates in utilization review and quality improvement activities.
• Other duties as assigned or as needed to meet departmental or organizational goals.
  
  

Qualifications & Skills

• Ability to understand and apply federal, state and local regulations and laws governing quality assurance and utilization review
• Knowledge of methods and procedures of admissions, discharges and consumer care in mental health programs
• Effective written and verbal communication skills
• Ability to use good judgment in making critical decisions about the necessity of treatment
  
  

Required Licenses or Experience

• Minimum two (2) years’ related experience in utilization review
• Minimum two (2) years’ experience in the mental health field
• Valid Driver’s license in state of residence and a safe driving record
• Bachelor’s degree in related field preferred
  
  

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EEO STATEMENT

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, veteran status, or any other characteristic protected by law.