Utilization Review Specialist

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🕒 October 9, 2024

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Legacy Healing Center

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

☁️ SaaS

Healthcare Insurance • Mental Health • SaaS

Legacy Healing Center is a network of luxury addiction treatment centers offering medical detox, inpatient and outpatient rehabilitation, mental health services, and aftercare across multiple U. S. locations. They provide evidence-based, trauma-informed care overseen by a board-certified medical director, accept major insurance, and offer specialized programs for populations like veterans, first responders, couples, and executives in private, resort-style settings.

📋 Description

• Review clinical information and supporting documentation to determine the medical necessity and appropriateness of proposed treatments, admissions, and services. • Work closely with therapists, counselors, doctors, and other healthcare professionals to ensure that patients are receiving the most effective and appropriate care. • Maintain thorough and detailed records of all reviews conducted, decisions made, and communications with relevant parties. • Continually update knowledge on clinical guidelines, evidence-based practices, and criteria pertinent to mental health and substance abuse care. • Collaborate with case managers to ensure a seamless patient care experience and to assist with treatment and discharge planning. • Communicate review outcomes, decisions, and feedback to healthcare providers, insurance companies, and other relevant stakeholders. • Conduct internal audits to ensure adherence to organizational policies and procedures as well as regulatory compliance. • Recommend process improvements and policy changes based on review findings, trends, and insights. • Provide training and education to clinical staff on utilization review processes, criteria, and best practices. • Develop and maintain positive relationships with insurance providers, healthcare teams, and other stakeholders to ensure smooth and effective processes. • Continually update UR reporting via Excel to include authorized days, denied days, used and unused days by facility for each level of care.

🎯 Requirements

• A Bachelor’s or Master’s degree in a related field (e.g., Nursing, Social Work, Counseling, Psychology) or previous UR experience, 1+ years. • Prior experience in utilization review, case management, or a similar role, preferably in the substance abuse and mental health sector. • Strong understanding of medical terminology, treatment modalities, and clinical criteria such as the American Society of Addiction Medicine (ASAM) criteria or other relevant guidelines. • Excellent communication, analytical, and decision-making skills. • Familiarity with electronic health record systems and other relevant software such as KIPU, Excel, Word, portals, etc. • Preferred: Certification in Utilization Review, CAP, IADC, or similar. • Experience with insurance and reimbursement processes. • Knowledge of local, state, and federal regulations pertaining to mental health and substance abuse treatment.

🏖️ Benefits

• 401(k) • 401(k) matching • Dental insurance • Health insurance • Life insurance • Paid time off • Vision insurance