Utilization Review Specialist

About the job Utilization Review Specialist

Join Our Team:

As a Utilization Review Specialist, you will play a pivotal role in managing and performing various processes related to medical records requests, retrospective review requests, and chart appeals. If you are organized, efficient, and dedicated to maintaining the highest standards of quality in medical records management, we invite you to join us in our mission.

• Competitive salary commensurate with experience
• Comprehensive health, dental, and vision insurance plans
• Supportive and positive work culture
• Opportunities for career advancement
• LMSW, LMHC, LPC, or other healthcare-related credentials or experience preferred.
• Knowledge of behavioral health systems and various medical record platforms.
• Two years of experience in a hospital or healthcare insurance setting required.
• Bachelor’s degree from an accredited college or university in social work, mental health, nursing, or a related degree required.
• Manage and perform processes for medical records requests, retrospective review requests, and chart appeals.
• Review medical records for any quality issues before submission.
• Communicate with Supervisor and Quality Care team for assistance in meeting requests.
• Prepare and distribute medical records to comply with payor requests, medical record reviews/requests, pre/post payment documentation requests, and chart appeals.
• Prepare cover letters and chart appeal letters for medical necessity and claim denials.
• Timely communicate outcomes, follow-up instructions, options, and related information to relevant administrative staff. Respond to all calls and emails within one business day unless otherwise required.
• Document activity in Billing, UR software, and other approved locations.
• Organize and file documents for ease of access in approved locations.
• Communicate with Utilization Review team, Billing, Collections, and Verifications departments as needed for information relevant to medical records.
• Assist in compiling information for data analysis.
• Provide assistance in determining the likelihood of insurances covering treatment.
• Maintain patient confidentiality in accordance with state and federal law.
• Participate in internal information meetings, required in-service education and training, and company-wide performance improvement and compliance activities.