FLSA Status: Exempt
ABOUT VERTAVA HEALTH: Vertava Health is a leading national behavioral healthcare system for mental health and substance use disorders, providing a full continuum of services based on the individuals' varying needs at different times in their health and recovery journey. We apply evidence-based treatment modalities at every level of care and embed digital health tools to enhance and amplify clinical outcomes. With a growing list of Joint Commission accredited inpatient and outpatient locations across the country, a virtual care platform and a national network of healthcare providers, Vertava Health pioneers care that empowers people so that they can live out their best future.
In order to make this possible, we need an exceptional Utilization Reviewer who can meet the requirements below. Think you have what it takes to help us change lives all over the country?
The Utilization Reviewer is responsible for securing insurance authorizations for patients throughout the course of treatment. They obtain pre-authorizations for admitting patients and conduct or facilitate reviews and appeals across the continuum of care. To successfully gain and extend coverage, Utilization Reviewers leverage their knowledge of addiction and mental health treatment; nationally recognized medical and clinical criteria; and payer processes and expectations. They utilize excellent communication skills to build collaborative partnerships with clinical teams and insurance care managers.
Priority responsibilities include:
Submit pre-authorization application for admitting patients.
Track status of authorizations, last covered days, and next reviews.
Communicate with treatment teams about upcoming reviews and share insight about the likelihood of denials.
Support treatment teams in their decision to step patients down, prepare for a peer review, or organize for an effective appeal.
Proactively gather and review information from the treatment team and patient records to prepare for reviews and appeals.
Learn the expectations and criteria of each insurance provider to better make the case for medical necessity at each level of care.
Present clinical and medical information in a clear compelling manner, both verbally and in writing.
Pursue timely determinations to minimize unauthorized days.
Maintain meticulous documentation of all UR functions.
Juggle multiple tasks, communications, and timelines with multiple stakeholders for every patient in your caseload.
Be a strong advocate for our patients to receive the care they need and deserve.
Current, valid and unrestricted license in a mental health field, such as LICSW, LCSW, LMHC, LPC, RN, Ph.D,
Master’s Degree in Social Work, Counseling or related mental health field;
Minimum 2 years clinical experience in social work, counseling or equivalent
Minimum 2 years’ experience in Utilization Review or equivalent role
Familiarity with ASAM Level of Care Criteria
Insurance industry experience preferred
Strong clinical knowledge, prior patient care or related work experience in the substance abuse, behavioral and or mental health treatment field required.
Strong computer skills and knowledge of MS Office products, including skills in MS Excel required.
Strong written and verbal communication skills are a must have.
Demonstrates the ability to work closely with all staff to ensure that sufficient documentation is present to justify the clinical necessity and appropriateness of admission and continued stay
Working knowledge of insurance company criteria and guidelines for all levels of care including initial and continued stay reviews as well as ASAM Criteria.
Ability to communicate effectively both verbally and in writing with colleagues, clients, and insurance companies.
Knowledge of ICD-10 diagnosis for substance use and mental health disorders.
Ability to use hands and fingers, talk or hear
Ability to sit, stand, walk and reach continually. Ability to climb or balance, stoop, kneel, or crouch frequently
Ability to frequently lift and carry up to 20 pounds and occasionally lift and carry up to 50 pounds
Close vision required to see computer monitor, read documents, and operate copy and fax machine
Work environment is indoors and climate controlled. Occasionally exposed to outdoor weather conditions
Vertava Health is an EEO employer - M/F/Vets/Disabled