JOB SUMMARY
(Describe below the primary purpose and function of this job)
Performs concurrent reviews of outpatient and in-patient claims and performs authorization reviews of patient
services. Pursues receipt of high-quality medical outcomes for patients who require
precertification/preauthorization.


Essential Functions (Key Roles & Responsibilities)
Assesses, reviews, and assigns cases for utilization review (UR)
Assists with the negotiations of access to care in specified targeted areas; maintains relationships with providers
who provide services to patients and pursues a responsive system for authorization of services and approved
claims.
Assist with negotiating reimbursement rates with third party payers
Prepares clinical information for each concurrent review directly from the medical record.
Protects healthcare organization value by keeping information confidential; cautioning others regarding potential
breaches.
Facilitate effective communication between members of the treatment team
Maintains compliance with regulation changes affecting utilization management
Use appropriate screening criteria, knowledge and clinical judgment to assess patient needs.
Recognizes and reports appropriately cases of fraud, abuse or mis-utilization
Ensure quality and quantity of documentation in medical records for UR.
Performs other duties as assigned
Complies with all policies and standards



Qualifications

QUALIFICATIONS
Education
Degree Field of Study Required


Social work, Nursing, Licensed mental health counselor


Can this role accept experience in lieu of a
degree?
No
Licenses and Certifications
Licenses/Certifications Time Frame Required/
Preferred And/Or
Social Worker, Licensed Clinical [LCSW - State License] preferred
Social Worker, Licensed Independent Clinical [LICSW - State License] preferred
Registered Nurse [RN - State License] preferred
Licensed Mental Health Counselor [State License] preferred
Work Experience
Experience Details Years of Experience Required/
Preferred And/Or
clinical experience, including during training,
working with Rehab, psychiatric in-patient
population