Utilization Review Representative

The UR Specialist plays a crucial role in obtaining authorizations by performing a variety of functions including but not limited to, navigating electronic medical records and advocating for the patient; communicating with insurance carriers via phone, fax, web portals as needed and articulating medical necessities using specialized language while strictly adhering to compliance standards. Following Zealie’s UR process, the UR Specialist is responsible for the upkeep of all authorization notes, their days authorized, and next review dates . They assess continued treatment for clients that do not require authorization, and contact the facilities for more information as needed.

Responsibilities and Duties

Communicate with facilities assigned to you in order to obtain authorizations.

Follow Zealie’s UR process to document the dates and times contact was made to facilitate authorization.

Understand and communicate the verification of benefits to the facility if the need arises.

Facilitate and undertake peer reviews, or peer review scheduling.

Collaborate with facility treatment teams, to manage the clients level of care.

Understand medical necessity as it pertains to insurance authorizations, levels of care, and appeals.

Provide discharge referrals as needed to facilities. Provide discharge information to insurance.

Advocate on the patient’s behalf to ensure services will be covered by insurance company

Ability to adhere to HIPPA compliance standards

Ability to articulate medical necessity using medical dialect

Reviewing clinical documentation to assess medical necessity

Coordinating with providers and insurance companies for pre-authorizations and continued stay reviews

Ensuring compliance with payer guidelines and regulatory standards

Attending meetings with behavioral health facilities to discuss cases and address any questions or concerns they may have

Maintaining accurate records and participating in interdisciplinary team discussions

Qualifications and Skills

Minimum of 5-8 years experience in the Utilization Review process

Minimum of 2 years in Substance Abuse/Mental Health Treatment

Extensive knowledge of Substance Abuse/Addictions treatment; ASAM, and Medical Necessity criteria

Excellent organizational skills

Experience working in clinical appeals in the UR environment

Ability to successfully navigate private insurance requirements for proper submission of appeal

Effective communication skills, both verbal and written via phone and email

Proficiency utilizing related software programs such as Kipu, ZenCharts, BestNotes, SunWave etc.

Proficiency in Google Products including Google Workspace, Google Drive, Google Sheets, Google Docs

Ability to navigate various technology and software tools

Education and Experience

Bachelor’s degree or higher in Psychology or related field (Preferred)

5-8 years of experience conducting utilization reviews in healthcare/billing company settings.

2 years of experience working in mental health or behavioral healthcare setting

(Preferred):

Licensed Mental Health Clinician (LCSW, LMHC, LMFT)

Certified Addiction Counselor or Professional (CAC, CAP, MCAP, MAC)

Experience working in a behavioral health billing setting

Experience working in Substance Abuse/Mental Health Treatment Industry

Experience managing caseloads of 40+ per week

Experience obtaining an average of 200 authorizations per month

Knowledge in day-to-day operations of a psychiatric or behavioral healthcare setting

Comprehensive knowledge of all levels of care (Detox, RTC, PHP, IOP, OP, Aftercare)

About Zealie LLC

Zealie is a fast-growing Medical Billing company specializing in the Behavioral Healthcare industry. Our clients are substance use disorder treatment, addiction recovery, and mental health treatment centers that are saving lives on a daily basis. Our state of the art proprietary technology provides data analytics and revenue prediction tools to our clients to help them make strategic business decisions to grow their business. We are committed to delivering exceptional products and services to our clients and believe that our team plays a crucial role in achieving this mission. We are seeking motivated individuals with a desire to be a part of a winning team.