SERV, a well-established leader in behavioral healthcare in NJ, provides a wide range of quality residential and support services. We are in need of compassionate and caring individuals who can support our consumers in achieving greater independence and life satisfaction.
The Utilization Review (UR) Specialist is responsible for contacting external case managers and managed care organizations for pre-authorization and concurrent reviews throughout the duration of a consumer’s stay. The Specialist assists the treatment planning team in understanding insurance requirements, and completes UR audits for billing compliance.
Responsibilities- Reviews consumer records to ensure proper utilization of treatment resources; reviews records for proper documentation and necessity of treatment under applicable regulations;
- Establishes and maintains contact with managed care organizations;
- Establishes contact with insurance and managed care companies and verifies treatment benefits;
- Collects and records all information necessary for admission and extended stay;
- Conducts random continuing-stay reviews to ensure consumers in treatment require and are benefiting from the services they are receiving;
- Interfaces with other departments in matters of review decisions, discharge planning and fiscal communication
- Notifies psychiatrists and other clinical staff of the need for pre-certification and clinical reviews;
- Assists the treatment planning team in understanding insurance requirements for admission, continued stay, and discharge planning
- Reviews over- and under- utilization data with leadership;
- Completes UR audits to ensure compliance for billing purposes;
- Develops UR reports and statistics;
- Attends and participates in utilization review and quality improvement activities;
Qualifications & Skills
- Ability to understand and apply federal, state and local regulations and laws governing quality assurance and utilization review
- Knowledge of methods and procedures of admissions, discharges and consumer care in mental health programs
- Effective written and verbal communication skills
- Ability to use good judgment in making critical decisions about the necessity of treatment
Required Licenses or Experience
- Bachelor degree in psychology, counseling, social work, psychiatric nursing (RN), or related behavioral health field. Master's Degree preferred
- NJ RN, LCSW or LPC strongly preferred
- Minimum two (2) years related experience in utilization review
- Minimum two (2) years experience in the mental health field
- Valid Drivers license in state of residence and a safe driving record
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