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Utilization Review Specialist job in Reading at Tower Behavioral Health

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Utilization Review Specialist at Tower Behavioral Health

Utilization Review Specialist

Tower Behavioral Health Reading, PA Full-Time
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  • Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.
  • Documents all contact with payers and outcomes of reviews to ensure compliance. Participate in department in-service/training programs.
  • Provides consultation and guidance regarding admissions and continued stay criteria for a variety of payors.
  • Reviews clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.
  • Maintains current knowledge of applicable regulations and regulatory update in the behavioral health field.
  • Responsible for abundant data entry.
  • Validates that the request for authorization is complete or requests additional data from requesting physician, if necessary.
  • Follow all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.
  • Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.
  • Completes retrospective reviews on assigned cases when updated insurance information becomes available subsequent to admission or after discharge.
  • Communicates discharges timely to payors for all assigned cases.
  • Notifies attending physician, direct supervisor and unit staff of in-house denial decisions.
  • Collaborates with the treatment team regarding quality and completeness of documentation and serves as a resource for nursing and clinical staff on documentation requirements. 
  • Communicates with the responsible staff when clinical documentation is unclear, incomplete, unprofessional, or not relevant to the Master Treatment Plan goals and/or fails to supports medical necessity criteria for continued stay at the current level of care.
  • Participates in routine weekly chart auditing as assigned to ensure ongoing compliance with regulatory requirements.
  • Discusses utilization review decisions with patients and/or family members as appropriate.
  • Coordinates with clinical staff regarding progress of discharge planning for patients whose care has been denied.
  • Effectively manages time by scheduling concurrent telephonic reviews in advance when possible to efficiently manage caseload and work hours.
  • Attending clinical staff meetings to obtain clinical information pertinent to clinical reviews.

Recommended Skills

  • Auditing
  • Behavioral Medicine
  • Clinical Works
  • Consulting
  • Data Entry
  • Medical Records
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Job ID: UTILI055339

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