Become an Assembler! We are looking for a Utilization Review Specialist to join Assembly Health. If you are looking for a company that is focused on being the best in the industry, love being challenged, and make a direct impact on our business, then look no further! We are adding to our motivated team that pride themselves on being client-focused, biased to action, improving together, and insistent on excellence and integrity.
This is a full-time, non-exempt position reporting to the U/R Manager.
What you’ll do
- Evaluate patient medical records to determine the necessity and appropriateness of services provided.
- Analyze utilization data to identify trends, patterns, and opportunities for improvement.
- Provide recommendations to improve efficiency and effectiveness of care delivery.
- Manage utilization review schedule with providers and carriers
- Communicate with behavioral health providers to obtain necessary information and clarify clinical details.
- Communicate with insurance companies to resolve coverage issues and denials.
- Collaborate with medical and administrative staff to ensure compliance with established protocols and guidelines.
- Ensure that patient care meets regulatory requirements, accreditation standards, and payer requirements.
- Conduct reviews in a timely manner for each patient
- Stay updated on changes in regulations, standards, and guidelines affecting utilization review practices.
- Obtain prior authorizations for services as required by insurance companies and other payers.
- Monitor authorization periods and ensure timely renewals.
- Maximize authorizations from insurance providers for all levels of care
- Maintain accurate and detailed records of reviews, decisions, and communications.
- Effectively report and resolve any issues that affect authorizations
- Prepare and submit required reports to management, payers, and regulatory agencies.
- Review and appeal denied services as necessary, providing appropriate clinical information and documentation.
- Attends UR meetings to discuss activities/needs of UR department
- Execute additional duties as assigned, demonstrating diligence and meticulous attention to detail.
What we’re looking for
- Experience in healthcare, behavioral health (mental health, chemical dependency, or psychiatric nursing) preferred.
- Minimum of one year experience in utilization review.
- Comfortable working with common billing and EMR/EHR software
- Familiar with both inpatient and outpatient levels of care (MH and SUD)
- Knowledgeable of standard medical necessity criteria
- Adherence to strict confidentiality standards to safeguard patient care information and protect patient rights.
- Solid command of Microsoft Office applications, Google Suite, Adobe Acrobat, and other technologies
- Strong attention to detail and accuracy in data entry and financial records maintenance.
- Capability to manage multiple tasks and prioritize workload to meet deadlines.
- Keen Attention to Detail, Dependable, accountable, quick learner
- Exceptional interpersonal skills, organized, positive attitude, excellent verbal and written skills, excellent organizational skills, self-motivated and driven.
- Complies with all performance measuring regarding pre-certification, concurrent reviews, and appeals.
- Ability to function well in a fast-paced and at times stressful environment.
- Prolonged periods of sitting at a desk and working at a computer. Ability to lift and carry items weighing up to 10 pounds at times.
Why join the team?
- Be part of something special! We are growing both organically and through acquisitions.
- Career growth – your next role with Assembly might not be created yet and we are waiting for your help to chart the way!
- Ongoing training and development programs.
- An environment that values transparency
- Competitive Benefit Packages available, Paid Holidays, and Paid Time Off to enjoy your time away from the office.