Utilization Review Specialist

at  Catholic Charities Diocese of Trenton

JOB SUMMARY:

• Responsible for requesting and obtaining prior authorizations for treatment services from several treatment modalities within the agency in a timely manner to ensure no gaps in care or coverage.
• Authorizations are to be obtained from entities inclusive of but not limited to pay sources: Medicaid, Managed Care Organizations, NJSAMS, Commercial Insurance, etc.
• Responsible for managing and tracking prior authorization approvals and requests for all enrolled consumers.
• Coordinating with program leadership and staff to ensure clinical documentation (Progress notes, Treatment Plans, etc..) are completed in a timely manner and contains sufficient clinical content to support prior authorization services.

PREFERRED SKILLS:

• Knowledgeable about behavioral health services including ambulatory services such as Outpatient, Partial Care, and Addictions treatment.
• Knowledgeable about healthcare claims and processing including prior authorizations, CPT codes, MCOs, Medicaid, etc..
• Proficient in use of technology, various applications including Microsoft Office (including Excel), Electronic Health Records, and other databases such as NJSAMs, eMevs and Navinet.
• Strong skills related to clinical documentation
• Strong organizational and time management skills
• Excellent written and verbal communication, as well as interpersonal skills.
• Ability to multi-task and handle various responsibilities/duties/issues simultaneously while meeting timelines.
• Detail and problem solving orientated.

1. Verifying insurance(s)
2. Obtaining authorizations from insurance companies for services to be provided
3. Work with clinical team to appeal authorization denials
4. Maintain spreadsheet that tracks all pertinent data of the authorization
5. Building and maintaining professional relationships with treatment providers and insurance company representatives.
6. Collaborating with the treatment team to review service needs
7. Ensuring that there is clear communication between team members, insurance company representatives and consumers
8. Other duties as assigned by supervisor and Agency Leadership