Utilization Review Intake Specialist **Newton, KS** (Personal Services)

Job Summary: Under the administrative supervision of the Residential Treatment Director, the URIS is responsible for the implementation, and maintenance of utilization review programs to facilitate the use of behavioral health resources and increasing timely requests and decreasing denials, increase client time in service, decrease loss of treatment, and perform residential treatment intakes. The URIS shall operate in accordance with the policies set forth by the Board of Directors and shall abide by all applicable laws and regulations.

DUTIES AND RESPONSIBILITIES:

1. Submit for authorization, direct and monitor progress of clients thru continuation of care, ensuring the timely and appropriate authorizations are obtained.
2. Obtain the documentation outlining the Mental health and substance abuse problems according to clinical information given by counselors and/or directors. Follow criteria for medical necessity and appropriateness of care to obtain authorization(s)/continuation of care.
3. Work closely with the billing department to ensure ICD 10/DSM5 and CPT codes are accurate and input.
4. Ensure compliance with all performance measures regarding appeals, denials, higher level of care admission certification and concurrent review timeliness.
5. Compile and report daily review activity and facility statistics.
6. Perform client intakes into your assigned residential location in your catchment area.
7. Work with Administrative Assistants to verify subscriber eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment and coordination of benefits prior to obtaining authorization for treatment.
8. Coordinate with counselors to ensure proper documentation completed for submission to obtain authorizations and continued care authorizations.
9. Track benefit usage and advise appropriate parties of exhaustion of benefits.
10. Anticipate and troubleshoot claim and reimbursement issues.
11. Interact with third party payers to ensure coverage payment for patient care services provided.
12. Collect and monitor resource utilization data.
13. Actively participate with team meetings to discuss any issues related to utilization review processes or delays.
14. Participate in team meetings and actively takes part in clinical case discussions.
15. Act as liaison with third party insurers as appropriate to facilitate resolution of medical necessity determinations and fiscal denials. Coordinate issuance of notices in accordance with state and federal regulations and departmental guidelines.
16. Complete administrative intakes with new residential clients, ensuring clients feel welcomed into the facility and are able to provide informed consent for treatment.
17. Work in tandem with other members of the Utilization Review Team, receiving training, guidance, and consultation from the Director of Utilization Management.
18. Other duties as requested by the Residential Treatment Directors and the Director of Utilization Management.

QUALIFICATIONS:

1. High School diploma or equivalent required. Bachelors degree preferred.
2. A minimum of two (2) years experience in health care settings including utilization review, behavioral health and/or substance use preferred.
3. Working knowledge of utilization review procedures and network providers. Behavioral health and Substance Use community resources knowledge preferred.
4. Possesses demonstrated knowledge and understanding of relevant utilization and laws, rules, regulations, and reimbursement regarding managed care, commercial, federal, and state government programs such as Medicaid and Medicare.
5. Ability to understand, interpret and analyze program evaluation data and design.
6. Exceptional interpersonal skills required as well as ability to communicate effectively both verbally and in writing.
7. Excellent customer service skills required
8. Must be adaptable to change and have effective organizational skills.
9. Attention to detail required.
10. Must be able to work in collaboration with all members of the Mirror team.
11. Must be able to pass required security check.
12. Employees who have been diagnosed with any type of substance use disorder or behavioral addiction/compulsion must have sustained a minimum of two consecutive years of abstinence from all intoxicating substances and symptoms of their chemical and/or behavioral addiction; and must be in full sustained remission.
13. Must be proficient in basic computer skills.
14. Experience with EHR software required.
15. Physical requirements would include but not limited to standing, walking, talking, hearing, and lifting (40/50 pounds). Walking stairs may be required as well.
16. Ability to travel 15% of the time.