Utilization Review Specialist
Utilization review specialists assess plans for patient care and determine what treatment is appropriate and most cost-effective. They investigate disputed medical claims, coordinate utilization training for the medical staff, analyze electronic medical records, and inform medical staff whether a medical claim is denied, approved, under review, or under appeal. In many cases, the utilization review specialist serves as an advocate for quality patient care, cost reduction, and hospital quality standards.
Include the following essential functions – other duties may be assigned. Perform utilization review of developmental disability services, mental health and substance abuse intensive treatment services. Assess individuals’ current or proposed treatment plan to identify and address potential barriers to discharge and assist in transitioning care to a lower intensity service setting. Monitor the quality of care, and the member’s response to services and products delivered to determine if the goals of the plan of care are being achieved, whether those goals remain appropriate and realistic, and what actions may be implemented to enhance positive outcomes and promote optimal health. Assess and identify appropriate resource utilization, level of care and treatment options to develop a plan of care that will impact quality outcomes in a cost-effective manner. Actively promotes frequent communication between all team members, providers, individuals and their families to enable a smooth transition from one level of care to another to ensure quality care is provided. Effectively cultivate and maintain working relationships with all providers of care and employers by maintaining regular communications and professional rapport. Maintains an ICM case load of high risk members, utilizes the electronic case management system and provides proactive case management services. Maintains tracking logs for inpatient status, determinations, and appeals. Performs accurate data entry of all clinical information and authorizations. Manages stressful situations calmly and rationally and identifies potential high risk situations involving consumers through utilization review. Demonstrates an ability to effectively communicate utilization decisions to healthcare professions and develop collaborative treatment plans. Participate in projects utilizing the project management framework as assigned. Perform duties of Project Manager as assigned utilizing the Project Management Framework and associated tools Regular attendance required within routine business hours, Monday-Friday. May need to work an occasional weekend day or holiday depending on the volume of utilization reviews that are scheduled to be completed. Compliance with organizational policies and procedures, including code of conduct and attendance policy; and policies resulting from the HIPAA privacy rules regarding
Aligned Employment Resources, LLC dba Aligned Government Services is an Equal Opportunity Employer: disability/veteran/military spouse
This contractor and subcontractor shall abide by the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability.