Utilization Review Specialist
Do you have a passion to help people? Do you want to step into the behavioral health industry?
Purpose: Ensure timely and accurate utilization review by managing pre-certification, concurrent reviews, and retrospective reviews, supporting authorization accuracy, compliance, and documentation standards. Maintain up-to-date knowledge of payer requirements, collaborate cross-functionally, and contribute to departmental efficiency and improvements through clear communication, issue identification, and training.
Job Description:
1. Conduct timely precertification, concurrent, and discharge reviews, including peer reviews, retro reviews,
SCA/IFO requests, appeals, and eligibility checks to ensure efficient and accurate case management.
2. Organize and communicate information essential to completing daily reviews and follow-ups, ensuring
alignment with payer timelines and departmental priorities.
3. Document all clinical and authorization activity clearly and accurately in Jira and the EMR, supporting
compliance, reporting, and downstream processes.
4. Collaborate cross-functionally by communicating timely and relevant updates with other departments to
maintain a seamless and compliant revenue cycle.
5. Audit client charts and clinical documentation to confirm compliance with payer requirements, identify
documentation gaps, and escalate issues when needed.
6. Stay current on insurance carrier guidelines and medical necessity criteria, applying updated standards to
daily work and proactively identifying changes that may impact the UR process.
7. Assist in training facility staff, UR peers, and BPOs by providing education on best practices,
documentation expectations, and payer standards to improve authorization accuracy and turnaround
times.
8. Contribute to departmental efficiency by reviewing assigned work items, managing daily tasks and
follow-ups, and helping the team adapt to volume fluctuations or staffing gaps.
9. Participate in the department's L10 meetings, identify and bring issues, and develop and execute
quarterly rocks to drive alignment and improvements toward Cipher VTO.
10. Performs other related duties as assigned