Utilization Review Specialist

This is a fully remote position, open to applicants in Philippines.

📋 Description

• Oversee and submit preauthorization requests to insurance providers for clients seeking treatment in Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Standard Outpatient (OP) care levels.

• Verify that all necessary documentation is complete and accurately represents the clinical needs of the client.

• Liaise with insurance companies to obtain timely approvals for essential services.

• Negotiate and manage Single Case Agreements with insurance providers for clients requiring services that fall outside of network coverage.

• Track ongoing treatment needs and submit requests for continued authorization for Residential, PHP, IOP, and OP care levels to ensure seamless client care.

• Collaborate with the clinical team to ensure a thorough understanding of each client when requesting continued authorization.

• Participate in regular meetings with clinical staff to review client progress, treatment plans, and authorization requirements.

• Serve as a liaison among clients, clinical teams, and insurance providers to advocate for necessary care.

• Ensure that all utilization review activities adhere to relevant regulations, insurance policies, and organizational standards.

⛳️ Requirements

• Education: A Bachelor's degree in healthcare administration, social work, or a related discipline is preferred.

• Experience: A minimum of 3-5 years in utilization review, medical billing, or a related area, ideally within a behavioral health environment.

• Skills:

• - In-depth knowledge of insurance authorization processes, including preauthorization, continued authorization, SCAs, and various levels of care.

• - Exceptional communication and negotiation abilities, with a strong capacity to advocate for client needs.

• - Proficient in electronic medical records (EMR) systems and documentation standards.

• - Capability to collaborate with clinical staff and offer training on complex subjects in a clear and supportive manner.

• - Detail-oriented with excellent organizational and time-management skills.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and training.

• Supportive work environment with a focus on teamwork and collaboration.

• Comprehensive health and wellness programs.