Appeals/Utilization Reviewer
Addiction Campuses Nashville, TN $
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At Addiction Campuses, we believe in empowering individuals to restore a balanced life worth living through programs uniquely tailored to their needs. With safe, scenic campus environments located across the country, our comprehensive network treats substance addiction and mental health disorders medically, mentally and spiritually. Our customized programs support individuals with the coping skills, tools, leverage, support and accountability necessary in order to make lasting life changes.

In order to make this possible, we need exceptional people on our team. Think you have what it takes to help us change lives all over the country?

That’s why we are looking for an Appeals Utilization Reviewer. The Appeals Utilization reviewer is responsible for concurrent reviews for patients during the course of treatment based on medical necessity criteria and completed authorization from insurance companies. They are responsible for extended care reviews and authorization for the continuum of care.  They will Review clinical information for all appeals by using criteria that is nationally recognized, prepares reviews for cases that do not meet the required criteria. Other responsibilities include:

 

  • Proactively gather information from the treatment team and patient records
  • Apply clinical knowledge and present data in an articulate manner, both verbally and in writing
  • Familiarize self with each insurance provider’s requirements to prove medical necessity at every level of care offered in the facility.
  • Review medical and clinical records to ensure providers’ documentation meets insurance company criteria for appropriate level of care
  • Manage timelines and deadlines to ensure all provided care is authorized and approved by the insurance carrier
  • Communicate clinical information to insurance companies to obtain authorization to treat and or to facilitate continued stay. Utilize knowledge of billing process and clinical data to present viable arguments for insurance coverage

 

Job Qualifications:

  • 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
  • Team-oriented individual
  • 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

 

Skills/Special Requirements:

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.

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