Utilization Review Specialist

Job Title: Utilization Review Specialist Employment Status: Hourly (Non-Exempt)

Department: Clinical Salary Range: $22 to $25 Hourly

Reports To: Utilization Review Manager

MISSION STATEMENT: Leading adolescents to a new legacy.

The mission of CLEARFORK ACADEMY is to offer the highest quality and professional, substance abuse and mental health

treatment across a full continuum of care.

We are committed to treating patients and their families with the highest regard and respect as clients work toward reaching their

highest growth potential in their recovery process. This is accomplished through the strict adherence to the highest ethical standards

of care and policies and procedures set forth by the Texas Department of State of Health Services and the Joint Commission.

•  CLEARFORK ACADEMY ensures all clients are treated with compassion, respect, and dignity regardless of race, creed, age, sex, handicaps, or sexual orientation.
•  CLEARFORK ACADEMY employees are competent and responsible personnel who adhere to a strict code of professional ethics which include but are not limited to the prohibition of fraternization with patients, exploitation of clients, or any criminal behaviors.
•  CLEARFORK ACADEMY provides clients with accurate and complete information regarding the available services including the program rules, regulations, goals, and objectives of the program.
•  Appropriate availability of alternative treatment modalities is made at any time before during or after treatment if they are requested or the client’s needs are out of the scope of our practice.
•  CLEARFORK ACADEMY will ensure that discharge from treatment is conducted in accordance with Texas rule standards.
•  CLEARFORK ACADEMY provides both Texas and Joint Commission environment of care standards.
•  CLEARFORK ACADEMY will take all necessary and appropriate measures to maintain individual client records and information in a confidential and professional manner.
•  CLEARFORK ACADEMY strives to maintain positive relations with the surrounding community and pursues every reasonable action to encourage responsible client behaviors and community safety.

SUMMARY

The Utilization Review Specialist at CLEARFORK ACADEMY is responsible for advocating for authorizations and clinical appeals

(when necessary) from insurers after evaluation of medical records. Authorization/appeal requests are to be conducted based on

medical necessity, level of care, length of stay and existing authorizations and/or denials for clients. Duties include monitoring

client charts and records to evaluate care concurrent with their treatment, reviewing treatment plans, and requesting and recording

approvals from insurers. Collection and compilation of data is required according to applicable policies, regulations, and procedures.

AGE/PATIENT POPULATION(S) SERVED

Age of Patient Population Served: Adolescent and Young Adult Males & Females

Population Served: Persons meeting DSM 5 criteria for substance use disorders with or without co-occurring psychiatric illness.

ESSENTIAL DUTIES AND RESPONSIBILITIES

•  Verify benefits and eligibility for clients prior to admission.
•  Coordinate, generate, and track both incoming and outgoing correspondence with insurers and clients for services or prospective services.
•  Receive and coordinate all incoming calls from insurers for services.
•  Contacts third party payers to communicate clinical information/complete pre-certification and re-certification parameters.
•  Data entry for all authorizations according to company policies and procedures.
•  Collaborate with treatment team to discuss clinical authorization and quality of care.
•  Utilize clinical information and knowledge of medical necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.
•  Participate in clinical meetings, observation, and interaction with clients to support concurrent reviews.
•  Interfaces with other departments in matters of review decisions, discharge planning, and fiscal communication.
•  As pertains to the utilization review process, sends requested medical records to insurer on a timely basis and follows up tomake sure they are received.
•  Assists medical billing specialist to ensure that the billing and collection process proceeds in a timely, efficient manner.
•  Consistent and timely response to emails and other communications relating to utilization review.
•  Prepare and submit appeals as necessary.
•  Other duties and tasks as assigned

AGE SPECIFIC COMPETENCIES (ADOLESCENT AND YOUNG ADULT MALES & FEMALES)

•  Allows patient to maintain control; involves patient in decision-making and planning of care, as appropriate to condition and situation.
•  Encourages participation in care.
•  Demonstrates clinical knowledge of expected vital signs.
•  Identifies trauma, abuse/neglect or exploitation a client may have experienced.
•  Encourages family support.
•  Recognizes/respects concerns over interruption of work/plans/separation from family, etc.
•  Recognizes fears regarding potential lifestyle changes.
•  Encourages verbalization of fears and anxiety; maintains age-appropriate communication.
•  Demonstrates an understanding of developmental milestones of adolescents and young adult.

MINIMUM JOB REQUIREMENTS

Education, Training, and Experience Required:

•  Bachelor’s Degree in related field of study, Social Work, Psychology, Nursing, etc. (preferred)
•  1 to 3 years' work experience in a medical office setting or medical coding experience
•  Qualified Credentialed Counselor holding one of the following licensures: LPC, LMSW, LCSW, or Nursing (preferred)

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

•  Knowledge of industry standards as related to the position of medical billing specialist.
• Knowledge of insurance guidelines and other payer requirements and systems
• Familiarity with CPT and ICD-10 Coding as well as DSM-V and ASAM criteria
• Customer service skills for interacting with clients regarding medical claims and payment, including communicating with parents and family members of diverse ages and backgrounds
• Ability to triage priorities and handle conflict in a reasonable fashion
• Problem-solving skills to research and resolve discrepancies, denials, appeals, collections
• Knowledge of medical terminology likely to encountered in medical claims
•  Knowledge of legal and ethical issues related to patient’s rights.
•  Knowledge of crisis intervention techniques.
•  Knowledge of community/regional mental health resources.
•  Knowledge of principles and practices of customer service.
•  Professional readiness: Issues related to self-awareness, diversity, ethics, and continuing education
•  Knowledge of PC and Mac software programs, particularly Microsoft Word and Excel is required.
•  Written and oral communication skills; must be able to concentrate on work amid distractions such as noise, conversations, and foot traffic
•  Must be able to work independently with little direct supervision in an unstructured environment with multiple demands
•  Reading and writing level that can clearly express or understand complex concepts, assessments, directions and processes or sequences of events - level equivalent to at least two years of college.
•  Ability to represent the program well in interactions both inside and outside the facility
•  Demonstrates an understanding of the developmental milestones of adolescents and young adults

PHYSICAL DEMANDS/WORKING CONDITIONS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the

essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the

essential functions.

While performing the duties of this job, the employee is occasionally required to stand or sit for extended periods of time. The

employee must occasionally lift and/or move up to 25 pounds.

The job requires frequent contact with water (hand washing and cleaning) and working with body fluid and hazardous chemicals.

When under these working conditions, OSHA standards and universal precautions must be followed at all times.

While performing the duties of this job, the employee must be able to work in a fast-paced environment with minimal to high

volumes of stress.

 of stress.

EEOC STATEMENT

It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-

741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with

disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender

identity, or national origin.

EMPLOYEE ATTESTATION:

By signing below, I attest that I am competent and able to perform the duties and tasks as indicated above and as outlined in the

scope of the job requirements and knowledge, skills, and abilities requirements. I agree to abide by Clearfork Academy’s Core

Values of Honor, Unity, Sacrifice, Transparency, Legacy, Excellence, and Fun and understand that failure to do so may result in

immediate termination of employment.

Employee’s Signature___________________________________________________________ Date___________________________________

ACKNOWLEDGEMENT & RECEIPT:

I,___________________________________________________, acknowledge that I have reviewed and received a copy of this Job Description

and agree to my starting salary of $______________________ (circle one: annually per hour )

with an effective date of _______________________________ to be paid once every two weeks.

Employee’s Signature___________________________________________________________ Date___________________________________

Supervisor’s Signature___________________________________________________________ Date___________________________________

HR Representative Signature____________________________________________________ Date___________________________________