Utilization Review Specialist
- Boynton Beach, FL
- $65,000-80,000 per year
- Permanent
- Full-time
- Competitive salary commensurate with experience
- Comprehensive health, dental, and vision insurance plans
- Professional development opportunities
- Supportive and positive work culture
- Opportunities for career advancement
- LMSW, LMHC, LPC, or other healthcare-related credentials or experience preferred.
- Knowledge of behavioral health systems and various medical record platforms.
- Two years of experience in a hospital or healthcare insurance setting required.
- Bachelor’s degree from an accredited college or university in social work, mental health, nursing, or a related degree required.
- Manage and perform processes for medical records requests, retrospective review requests, and chart appeals.
- Review medical records for any quality issues before submission.
- Communicate with Supervisor and Quality Care team for assistance in meeting requests.
- Prepare and distribute medical records to comply with payor requests, medical record reviews/requests, pre/post payment documentation requests, and chart appeals.
- Prepare cover letters and chart appeal letters for medical necessity and claim denials.
- Timely communicate outcomes, follow-up instructions, options, and related information to relevant administrative staff. Respond to all calls and emails within one business day unless otherwise required.
- Document activity in Billing, UR software, and other approved locations.
- Organize and file documents for ease of access in approved locations.
- Communicate with Utilization Review team, Billing, Collections, and Verifications departments as needed for information relevant to medical records.
- Assist in compiling information for data analysis.
- Provide assistance in determining the likelihood of insurances covering treatment.
- Maintain patient confidentiality in accordance with state and federal law.
- Participate in internal information meetings, required in-service education and training, and company-wide performance improvement and compliance activities.
- Perform other duties as assigned.