Utilization Review Specialist Job at AQUILA OF DE INC
Description:
The Utilization Review Specialist is responsible for managing the processes and systems required for the submission and receipt of information to and from Managed Care Organizations (MCOs), Insurance Companies, and other entities that authorize and fund the services delivered to clients; builds and maintains productive relationships with payers; assist with training of staff on proper documentation of medical necessity criteria required to obtain prior authorizations.
Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
Abstracts data from records and maintains statistics.
Determines patient review dates according to established diagnostic criteria.
May assist review committee in planning and holding federally mandated quality assurance reviews.
Requirements:
Licensed Practical Nurse, RN, Bachelor's Level Social Worker
Experience in Utilization Review
Experience with ASAM
Experience with mental health, substance use disorder and co-occurring disorders
Experience with Delaware Medicaid Managed Care Organizations
Job Type: Full-time
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