UR - Utilization Review Specialist

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conduct comprehensive utilization review activities for behavioral health services, ensure adherence to payer guidelines, medical necessity criteria, and regulatory requirements.
• Review and analyze clinical documentation, treatment plans, and patient records
• Collaborate with therapists, physicians and other clinical staff to obtain required information and ensure seamless continuity of care.
• Good understanding with EMR systems ifor documentation review, tracking, and utilization management.
• Manage prior authorizations through payer portals.
• Verify referrals/authorizations for denied procedures. Obtain and work with the practice to correct any referrals/authorizations for denied procedures.
• Checking insurance eligibility and benefits for patients, as needed.
• Reviewing patient accounts for accuracy and completeness and obtaining any missing information.
• Ensure accurate submissions, benefit verification, timely follow-ups, and successful approvals.
• Following up on unpaid claims within standard billing cycle timeframe for the client and carrier.
• Checking each insurance payment for accuracy and compliance with contract discount, as necessary.
• Calling insurance companies regarding any discrepancy in payments if necessary
• Identifying and billing secondary or tertiary insurances.
• Reviewing accounts for insurance of patient follow-up including review and research of self-pay, refund accounts for insurance.
• Researching and appealing denied claims. Coding research appeals and corrections at the discretion of the client and management.
• Answering patient or insurance telephone inquiries pertaining to assigned accounts.
• Understand CPT codes and ICD-10 codes and when these can be changed or not.
• Understand the insurance carriers requirements for submitting claims and appeals.
• Understand special situations and procedures that relate to the specialty you work on.
• Performs other duties as assigned.

MINIMUM JOB REQUIREMENTS

Education, Training, and Experience Required:

• Bachelors Degree or a 3 year Diploma or equivalent is required.
• Two (2) years of medical billing AR Calling/Analysis experience is required. Two (2) years of UR experience is preferred
• Willing to work night shifts as per US time zones

Knowledge/Skills/Abilities:

• Excellent interpersonal skills.
• Solid computer/technology skills.
• Excellent ability to analyze problems and select proper resolution.
• Excellent written and oral communication skills.
• Excellent ability to organize tasks and work independently.
• Ability to multi-task.
• Effectively implement and manage assigned programs and functions.
• Establish and maintain effective working relationships with individuals at all levels of the organization.
• Ability to communicate effectively and clearly with people from diverse backgrounds.
• Ability to competently use Microsoft Office, including Word, Outlook, Excel, and appropriate practice management software.

Perks and Benefits

As per market standards