Utilization Review Specialist

At BayMark Health Services we do things differently. Our workforce are not just employees, they are members of a large, diverse, mission and values driven family who are collectively committed to changing and saving lives affected by addiction. We celebrate being an Employer of Choice committed to providing a recovery friendly and equal opportunity workplace.

Responsibilities:

• Manages and performs utilization reviews to ensure adherence to federal regulations and payer requirements
• Assists in maintaining records, answering correspondence and preparing and disseminating reports.
• Familiar with treatment concepts, practices and facility procedures that impact patient care
• Applies approved medical necessity criteria towards conducting admission and continued stay record reviews
• Acts as liaison with third party payers, managed care companies and billing company around communication specific to authorizations for approved patient admissions, continued stay, discharge planning and aftercare.
• Completes all utilization reviews for Detox, Residential, PHP, IOP and Community IOP levels of care.
• Sends out admission notifications when assessments are complete.
• Answers any questions regarding scheduling, etc.
• Obtains approval for alternative levels of care.
• Ensures that insurance company’s specific questions are addressed in Utilization review interactions – may require communication with clinicians and providers.
• Communicates denials or possible denials with treatment team to coordinate discharge plan.
• Requires after hours communication (text, email) with Chief Executive Officer, facility financial representatives or billing company when admission nursing assessment is complete.
• Occasionally provides information that billing company may send to appropriate parties.
• Adhere to all confidentiality laws and maintain ethical, professional boundaries with clients.
• Active participant in performance improvement and quality assurance initiatives that relate to documentation, specific payer initiatives and any payer-initiated action plans to improve facility performance
• Communicates any concerns relating to documentation and patient care needs to the appropriate departmental leader based on review of patient charts.
• Active participant of facility treatment team meetings
• Applies knowledge of managed care, pre-certification, concurrent reviews, medical/psychiatric diagnoses, medications and insurance payment practices.
• Helps with any other related activities or duties that are required.

Qualifications:

• LPN, RN or Master’s prepared clinician
• 3+ years' experience in healthcare setting.
• Excellent written and verbal communication skills.
• Strong organization and coordinating skills.
• Strong analytical thinking and ability to handle multiple tasks concurrently.
• EHR systems experience.
• Satisfactory drug screen and criminal background check.

Benefits:

• Competitive salary
• Comprehensive benefits package including medical, dental, vision and 401(K)
• Generous paid time off accrual
• Excellent growth and development opportunities
• Satisfying and rewarding work striving to overcome the opioid epidemic

COVID-19 considerations:

Everyone will be asked to be in compliance with the most recent COVID guidelines from CDC, State, County and City.

Here is what you can expect from us:

BayMark Health Services is committed to helping people achieve lasting sobriety through comprehensive care and compassionate support. Founded by and staffed with individuals in recovery themselves, we treat residents with the respect and dignity they deserve. Our Canterbury center provides individualized care and evidence-based clinical approaches in an environment that promotes healing.

BayMark Health Services is committed to Equal Employment Opportunity (EEO) and to compliance with all Federal, State and local laws that prohibit employment discrimination on the basis of race, color, age, natural origin, ethnicity, religion, gender, pregnancy, marital status, sexual orientation, citizenship, genetic disposition, disability or veteran’s status or any other classification protected by State/Federal laws.