Utilization Reviewer/Authorization Specialist

REPORTS TO:  Billing Manager                                                                                    FLSA Status: Non-Exempt   

SCHEDULE:  Monday-Friday 8am-5pm; occasional evening or weekend work; hybrid

POSITION SUMMARY:  Oversees all duties for managing insurance authorizations and reauthorizations for outpatient clients.  This would include obtaining initial authorizations for all Peer Support Services, Psych Education, and TCM and any reauthorizations this might require.  Work closely with Billing for tracking purposes of the above services.

GENERAL RESPONSIBILITIES:

1. Assist insurance companies regarding pre-authorization for services, including but not limited to residential, IOP, and outpatient services. 

     2. Perform prospective/concurrent, and retrospective reviews to justify clinical necessity for requested Outpatient                       Services. 

     3. Cross train in the billing department to assist with audits and billing.

     4. Assist in medical record request for MCO pre-payment of services.  

     5. Be well versed in all policies and rules regarding preauthorization and reauthorization for care of clients. 

     6.Work with the billing department to track pre-authorization needs. 

     7.Work with the billing department to resolve pre-authorization denials.  

     8. Audit records prior to authorization request to ensure documentation is accurate. 

BACKGROUND/EDUCATION/SKILLS:

1. Excellent written and oral communication skills as well as the ability to work and meet deadlines.
2. Strong computer and customer service skills are required.
3. Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act-HIPPA); computer applications/software to include Microsoft Office programs/ MS Outlook (email), Excel, and internet familiarity.
4. Understand and apply state, federal, and local regulations and laws governing quality assurance and utilization review.
5. Work independently
6. Use good judgment in order to make critical decisions about the medical necessity of treatment.
7. Time management skills – there could be daily deadlines associated with this position that could cause significant levels of stress to some individuals. The position must deal with other staff and insurance representatives as needed on a variety of issues

QUALIFICATION REQUIREMENTS: 

Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); computer applications/software to include Microsoft Office programs/ MS Outlook (e-mail), and internet familiarity.

This person works with other health care providers to ensure appropriate and consistent administration of plan benefits through collecting clinical information required to assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies and plan benefits.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

SKILLS REQUIRED: 

    1.    Excellent organization and time management skills with ability to work independently. 
    2.    Effective verbal and written communication skills.  
    3.    Ability to maintain effective interpersonal relationships. 
    4.    Critical thinking, independent judgement, and confidence to carry out decisions. 
    5.    Knowledge of, and ability to apply state, federal and local regulations and laws governing medical coding and billing. 

WORKING CONDITIONS: 

Physical Demands:  

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Must be able to sit, stand, bend, reach overhead, and lift up to 10 pounds; travel outside of the office and/or attend meetings both during and after normal work hours, on and off-site.  Exerting up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects. May involve walking or standing for brief periods of time.  Requires about 6 hours of sitting and no more than 2 hours of standing or walking in an 8-hour workday. No significant stooping is required. 

Environmental Conditions:  

The employee will work indoors in a commercial setting with central heating and air conditioning. 

Mental Demands:  

There are several daily deadlines associated with this position, which may cause significant levels of stress for some individuals.  The position must deal with the staff and insurance representatives daily on a variety of issues.   

AT-WILL EMPLOYER STATEMENT: 

Revive is an At-Will employer.  This means that regardless of any provision on this form, the company or employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.  Nothing in this employee's job description or in any document or statement, written or oral, shall limit the right to terminate employment at-will.  No officer, employee or representative of the company is authorized to enter into an agreement, express or implied, with any employee for employment for a specified period unless such an agreement is in a written contract signed by the Executive Director of the company.   

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT: 

Revive is an Equal Opportunity Employer, in compliance with federal, state, and local laws prohibiting discrimination.  No person shall be discriminated against in employment, training, promotions, transfers, rates of pay, layoffs, any form of compensation or any term or condition of employment on the basis of race, sex, color, religion, national origin, age, marital status, disability, tobacco use, gender identity, genetic information, military status, pregnancy or childbirth, status as a smoker or non-smoker, veteran status or any other protected class under federal, state or local law.