Utilization Review Specialist

Utilization Review Specialist-Residential Program

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Job Summary

Odyssey House Louisiana, Inc. is seeking full-time Utilization Review Specialists for the Adult Residential program. The schedule for the position is Monday-Friday 8am-5pm. This position provides high quality client-focused health care services that meet the assessed and individually planned needs of all clients in the Residential Program. The Utilization Review Specialist will work as a part of the multi-disciplinary team (MDT) and is responsible for maintaining standards of care and competency, ethical treatment of patients, understanding of addiction and the medications used for detoxification purposes, managing symptoms of withdrawal with comprehensive triage, consistent documentation on care, review and implementation of treatment orders.

Responsibilities and Duties

It is the duty and responsibility of the Utilization Review Specialist to:

·        obtain pre-certification and continued stay authorizations on behalf of the patient and provider using ASAM (American Society of Addiction Medicine) criteria to review clinical information with insurance companies;

·        communicate with clients to obtain and relay necessary clinical information;

·        communicate authorization information internally within the agency to enable the stages of the billing process to take place;

·        analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients;

·        analyze patient records to determine legitimacy of admission, treatment, and length of stay in the health-care facility to comply with government and insurance company reimbursement policies;

·        review applications and assist in approval for patient admission or refer cases to the Admissions Supervisor for review and course of action when case fails to meet admission standards;

·        compare inpatient medical records to established criteria and confer with medical, nursing, and other professional staff to determine legitimacy of treatment and length of stay;

·        report out and maintain statistics on data from medical records;

·        determine patient review dates according to established diagnostic criteria;

·        assist review committee in planning and holding federally mandated quality assurance reviews;

·        aid in initial and concurrent/continued stay reviews and arrange peer to peer conferences;

·        conduct health information groups as requested by the Senior Program Manager;

·        complete accurate census and count on all clients daily as instructed by the Admissions Supervisor;

·        transcribe relevant paperwork for MDT;

·        review individual patient needs with medical doctor as needed;

·        assist support staff in delivery of patient care;

·        participate in monthly in-services;

·        assist Admissions Supervisor with clinical authorizations;

·        communicate effectively with insurance providers;

·        maintain a clean, organized work environment;

·        maintain professionalism with staff members and clients at all times;

·        maintain privacy of patients by protecting health information protected under Health Insurance Portability and Accountability Act;

·        make rounds with nursing staff during visits; and

·        perform other duties as assigned.

Qualifications and Skills

Required

Minimum qualifications include the following:

·        Master’s degree in a Counseling, social work, psychology and another helping profession

·        Familiar with ASAM (American Society of Addiction Medicine) criteria

·        At least 1 year of case management experience

·        6 months substance abuse treatment experience 

·        Proficient in MS Office 365 Suite

·        Excellent written and verbal communication skills

Preferred

Preferred qualifications include the following:

·        1 year of Electronic Health Record and Practice Management experience

·        2 plus years of substance use disorder utilization review experience

·        Familiarity with ASAM criteria, substance abuse treatment, and HIPAA

·        Excellent comprehension and analytical skills

·        Excellent customer service skills

Compensation and Benefits

Competitive compensation and benefits package includes insurance (health, dental, vision, life, long-term and short-term disability), leave benefits and 401k match.