Utilization Review Specialist

POSITION SUMMARY: The Utilization Review Coordinator is responsible for communicating substance abuse and mental health clinical information to managed care/insurance companies and payer services to obtain authorization for treatment services provided by Sunshine Behavioral Health. The Utilization Review Coordinator must be familiar with admissions pre-certification process as well as concurrent and discharge reviews. Extensive knowledge of medical terminology, substance abuse and mental health disorders, ASAM criteria and ICD-10 diagnosis codes is necessary.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Complete assessments and pre-certifications for clients.

1. Communicate necessary information received toappropriate staffina timelyand efficientmatter.

1. Demonstrate understanding of medical terminology.

1. Demonstrate understanding of policy deductibles, co-pays, co-insurance and out of pocket maximums, out of network deductions and exclusions.

1. Demonstrate knowledge of EOB interpretation.

1. Daily use of ten key, dataentryand spreadsheets applications.

1. Communicate effectively with peers andsupervisorto address billing and claim issues.

1. Follow all HIPAA, compliance,privacyand confidentiality standards.

1. Participate indevelopmentof Quality Improvement projects.

1. Follow all practices detailed inthe companiesPolicies and Procedures Manual and Employee Handbook.

1. Attend andparticipatein staff meetings andtrainings.

1. Demonstrateexpertisein Psychiatric and Addiction Disorders.

1. Engage inappropriate writtenand verbal communication with families, insurance companies and otherprofessional.

1. Demonstrateabilityto work with Excel,Wordand electronic chanting.

1. Ability to work with minimal supervision.

1. Organized and detail oriented.

1. Other dutiesas assigned.

ESSENTIAL KNOWLEDGE, SKILLS, AND ABILITIES: 

Knowledge: The UR Coordinator will:

1. Possessproficiencyin Excel,Wordand electronic charting.

1. Demonstrateabilityto multi-task.

1. Demonstrateabilityto work with minimal supervision.

1. Basic knowledge of HIPAA.

1. Possess excellent customer service skills.

1. Demonstrateabilityto work under pressure.

Abilities: To excel in this position the incumbent should be able to demonstrate the following competencies:

1. Problem Solving– The UR Coordinatorwill be able toidentifyand resolve problems in efficient and effective ways.

1. Ethics – Treat clients, staff, co-workers, visitors, contractors, and guests ofSunshine Behavioral Healthwith respect and dignity; work ethically and uphold the values and standardsorSunshine Behavioral Health.

1. Attendance, Punctuality, Reliability – Arrive on-site, on-time, as scheduled, consistently with a professional disposition. Ensure all work responsibilities are coveredin the event ofan absence or scheduled vacation. 

1. Leadership – Constant development of staff,co-workersand clients, ineffortto achieveeach individual’shighest potential.

1. Strong Character – Staying calm under pressure is essential. Having an approachable demeanor without compromisingSunshine Behavioral HealthStandards of ethics and workmanship. 

1. Flexibility–Openness to different and new ways of doing things; willingness tomodifyone's preferred way of doing things.

1. Organization – Must be highly organized and efficient in managing the necessary daily client/staff demands and tasks associated with them. 

QUALIFICATIONS AND PREFERENCES: 

1. A minimum of twoyearof experience with Utilization Review.

1. HS Diploma, college degree preferred.

1. Excellent customer service skills.

1. Valid Driver’s License.

Sunshine Behavioral Health is an equal opportunity employer and prohibits discrimination and harassment of any kind.