Utilization Review Specialist - LPN Required

Position Overview:

The UR Representative is responsible for conducting Utilization Reviews (UR) to ensure appropriate authorization for behavioral health services. This role involves reviewing cases via multiple platforms, coordinating peer reviews, entering authorization data, following up on approvals, and maintaining clear communication with facilities. Strong knowledge of levels of care, prior authorization processes, and behavioral health policies is required.          

Key Responsibilities:

Utilization Review & Authorization Management

• Lead training for new onshore Reps and oversee development of payer-specific training materials.
• Conduct CDI and documentation standardization training across customers to improve quality and compliance.
• Partner with QA to perform ongoing UR audits and monitor accuracy trends.
• Provide educational feedback to facilities on what supporting documentation is required to support authorization approvals. 
• Support knowledge transfer to Cognizant Training Leads and ensure timely dissemination of new payer/process updates.

• Conduct Admin, Concurrent Utilization and Retro Reviews via:

• Live Reviews

• Voicemail Reviews

• Fax Reviews

• Portal Reviews

• Coordinate Peer Reviews as needed.

• Provide Assignment of Responsibility (AOR) form templates at admission if required by the facility.

• Enter UR authorization information into the facility's EMR billing system and internal workflow systems.

• Ensure follow-ups on pending authorizations to secure required approvals and documentation.

Documentation & Tracking:

• Accurately document and track all UR activities in Salesforce and other designated systems.

• Assist with document retrieval from EMRs when necessary.

Communication & Coordination:

• Act as a liaison between the facility and internal teams.

• Send morning and end-of-day emails to facilities with status updates.

• Provide weekly email summaries to keep stakeholders informed.

Expertise & Compliance:

• Maintain a strong understanding of levels of care, insurance authorization requirements, and behavioral health regulations.

• Identify and address gaps in documentation that could impact authorization approvals.  

• Review clinical documentation with a licensed nursing perspective to identify clinical charting deficiencies keeping highest level of care from being approved and communicates findings with facilities.

• Clinical resource for escalations and complex case reviews prior to engaging client assistance. 

• Ensure all UR requests for Authorization comply with relevant policies and payer requirements, assist in providing information/training to facility to ensure above.

• Additional Duties as Assigned: Assist with other tasks that align with UR and prior authorization responsibilities as needed.

Requirements:

• Educational Background: Active and unrestricted Licensed Practical Nurse (LPN) credential.

• Experience: Minimum of 2 years of Behavioral Health Clinical, Utilization Review, case management, or prior authorization experience preferred. 

• Expert Industry Knowledge: Knowledge of insurance authorization processes, levels of care, and medical necessity criteria.

• Collaboration & Communication: Excellent verbal and written communication for facility interactions.

• Detail-Oriented: High level of accuracy, Strong organizational, follow-up, and documentation skills.

• Technical skills: Proficiency in EMR systems, Salesforce, and other workflow platforms.

• Adaptability and flexibility: Ability to prioritize tasks and manage multiple authorization cases simultaneously.