Utilization Review Specialist

🕒 vor 15 Tagen

🏈 Alabama – Remote

🏈 Alabama – Remote

💵 $60.000 - $70.000 / Jahr

⏰ Vollzeit

🟢 Junior

🟡 Mittelstufe

🚫👨‍🎓 Kein Abschluss erforderlich

👻 Geisterscore 0%

Was es bedeutet: wie wahrscheinlich diese Stelle offen bleibt, ohne dass aktiv eingestellt wird.So liest du es: 60 % oder höher heißt, wir halten das für einen Geisterjob. Niedrigere Werte sind weniger bedenklich.Wie wir werten: Dauer offen, Neuveröffentlichungen, offene Stellen vs Teamgröße, wie schnell Stellen geschlossen werden, und ob ein Gehalt angegeben ist.Hinweis: eine Schätzung aus öffentlichen Daten, kein Urteil über das Unternehmen. Echte Stellen können hoch punkten, nutze es also als Hinweis, nicht als Fakt.

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Bradford Health Services

WebsiteLinkedInAlle Stellen

1001 - 5000 Mitarbeiter

Gegründet 1977

🏥 Gesundheitswesen

🧘 Wellness

🤝 Non-Profit

Healthcare • Wellness • Non-profit

Bradford Health Services ist ein führender Anbieter von Suchtbehandlungsprogrammen und bietet eine breite Palette von Dienstleistungen, um Einzelpersonen auf ihrem Weg zur Genesung zu unterstützen. Mit Einrichtungen im gesamten Südosten bieten sie stationäre und ambulante Rehabilitation, Entgiftungsdienste und verschiedene Spezialprogramme, die auf die einzigartigen Bedürfnisse ihrer Patienten zugeschnitten sind. Ihr Engagement für erschwingliche, evidenzbasierte Behandlung gewährleistet, dass Einzelpersonen die Unterstützung erhalten können, die sie benötigen, um ihr Leben von der Sucht zurückzuerobern.

Beschreibung

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews • Obtain, document, and monitor authorizations across the continuum of care • Review medical records and collaborate with treatment teams to obtain clinical information supporting medical necessity and requested levels of care • Present clinical information to payer representatives using medical-necessity criteria and payer guidelines • Maintain authorization records in electronic medical records, payer portals, tracking systems, and other applications • Monitor caseloads and authorization deadlines; complete follow-up and escalate unresolved barriers • Identify clinical documentation gaps and communicate needs to clinicians, providers, or leaders • Coordinate with clinical and case-management teams on transitions, discharge planning, and level-of-care changes • Escalate adverse determinations requiring peer-to-peer review, reconsideration, appeal, or leadership intervention • Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations • Review payer correspondence and adverse determinations and complete follow-up • Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives • Follow utilization review policies, workflows, escalation pathways, and documentation requirements • Maintain knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and service-line requirements • Collaborate with Utilization Review leadership, admissions, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners • Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies

🎯 Anforderungen

• High school diploma or equivalent required • Minimum 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related function • Behavioral Health and/or Substance Use Disorder experience required • Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up • Ability to interpret clinical documentation and communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge • Ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation • Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality • Working knowledge of HIPAA and 42 CFR Part 2 requirements • Bachelor's degree in a related healthcare discipline preferred • Knowledge of ASAM Criteria and behavioral-health levels of care preferred • Experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers preferred • Experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals preferred • Active clinical license or relevant certification preferred but not required • Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications preferred

🏖️ Vorteile

• 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 • Generous PTO – A robust paid time off policy • Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week • Great Place to Work® Certification • Supportive and rewarding workplace