Utilization Review Specialist

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🕒 Julho 22

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Cornerstone of Recovery

SiteLinkedInTodas as Vagas

51 - 200 funcionários

Fundada em 1989

🏥 Saúde

🧘 Bem-estar

🌍 Impacto Social

Healthcare • Wellness • Social Impact

O Cornerstone of Recovery é uma instalação de tratamento para dependência localizada perto de Knoxville, TN, dedicada a ajudar indivíduos a superar o vício em drogas e álcool. Oferecendo programas abrangentes de reabilitação residencial e ambulatorial, o Cornerstone visa fornecer cuidados eficazes e acessíveis através de uma equipe compassiva de profissionais médicos e de apoio à recuperação. Com foco em tratamento personalizado, o Cornerstone atende aqueles que precisam desde 1989 e está comprometido em promover esperança e cura em um ambiente comunitário de apoio.

Descrição

• Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services. • Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details. • Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements. • Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards. • Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.

🎯 Requisitos

• Bachelor’s degree in Nursing, Health Administration, or a related healthcare field. • At least 2 years of experience in utilization review, case management, or clinical healthcare roles. • Strong knowledge of medical terminology, clinical procedures, and healthcare regulations. • Familiarity with insurance authorization processes and healthcare reimbursement models. • Excellent analytical, communication, and organizational skills. • Preferred Qualifications: Registered Nurse (RN) license or equivalent clinical certification. • Experience with electronic health records (EHR) systems and utilization management software. • Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager). • Prior experience working with managed care organizations or insurance companies. • Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.

🏖️ Benefícios

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits. • Expanded Coverage – Options for domestic partners and a wider network of in-network providers. • Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching. • Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more. • Student Loan Repayment – Available for nurses and therapists. • Retirement Benefits – 401(k) plan through Voya to help employees plan for the future. • Generous PTO – A robust paid time off policy to support work-life balance. • Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.