Utilization Review Specialist
Unity Point - Proctor Hospital ARC
Full-Time 40 hours/week, Benefitted
1st Shift 8:00 am - 5:00 pm
The Utilization Review Specialist works with the treatment team to provide insurance authorizations and reviews for patients.
About UnityPoint Health - UnityPlace:
UnityPoint Health - UnityPlace is proud to offer the most comprehensive addiction and mental health services in the Peoria, Illinois region to you and your family. UnityPlace was formed by the joining of UnityPoint Health®, Human Service Center and Tazwood Center for Wellness in April of 2019. UnityPlace is a new non-profit organization dedicated to meeting the growing behavioral health care needs of the community. Our compassionate and committed treatment team is comprised of many experts from psychiatry and addiction medicine.
Our goal is to deliver comprehensive behavioral healthcare to optimize the patient's well-being. It is our privilege to partner with our patients on their journey of healing.
As a member of the UnityPlace Team, our team members are eligible for a benefits package including:
Additional benefits are available, apply today to discuss our full benefits package!
ENSURES PATIENTS’ INSURANCE REQUIRMENTS ARE CONDUCTED FROM INITIAL CONTACT THROUGH ADMISSION.
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· Monitors patient’s insurance requirements.
· Works with the Patient Financial Services Department to ensure patients meet financial eligibility for treatment services.
· Coordinates with the treatment team in planning for insurance reviews.
· Maintains appropriate contact with patient’s insurance companies.
· Conducts all insurance reviews and pre-certs, as needed, to ensure patient’s insurance needs are being addressed.
· Is knowledgeable of and capable of utilizing ASAM criteria during insurance reviews and precertification of patients.
· Attends and Participates in treatment team meetings to be knowledgeable in the patient’s care to report to insurance companies.
· Conducts quality assurance chart reviews, at the Peoria Site, monthly on 15% of patients at each level of care.
· In collaboration with the Program Managers of each unit, ensures that Quality Dashboards are up to date with current information.
· Ensures that action plans are carried out, if needed, for any one indicator that is out of compliance 3 times in a row.
· Facilitates monthly QA meetings, ensuring that all sites are completing quality dashboards and meeting outlined targets.
CLINICAL EXCELLENCE/PATIENT CARE: Plays a pivotal role in interdisciplinary oversight of quality patient care on unit. Reports all issues or concerns to the Program Managerscore: N/A
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Utilization of Resources and Effective Communication. Is knowledgeable of resources and utilizes effective communication skills in interactions with team members, patients, visitors and physicians.
· Keeps data related to authorized days used and reports this data to the program manager monthly.
Basic UPH Performance Criteria
· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
· Demonstrates ability to meet business needs of department with regular, reliable attendance.
· Employee maintains current licenses and/or certifications required for the position.
· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
· Completes all annual education and competency requirements within the calendar year.
· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
· Attends trainings and meetings as requested by the manager.
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
Past experience in addiction treatment or insurance reviews.
Psychology, Counseling, Social Work state licensure preferred.
Advanced reading, writing and oral skills.
Ability to respond appropriately to customer/co-worker
Interaction with a wide variety of people
Maintain confidential information
Ability to project a professional, friendly, helpful demeanor.
Basic computer knowledge: Uses word processing, spreadsheet, e-mail application, and web browser.
Comfortable within Windows OS and learning new applications.
Ability to utilize an electronic medical record.
Must have control over personal use of all mood-altering chemicals and behaviors.
If recovering from an addiction, must currently have a minimum of 2 years of uninterrupted recovery and must actively treat this addiction by appropriate recovery practices.
Use of usual and customary equipment used to perform essential functions of the position.
Work may occasionally require travel to other UPH facilities/hospitals.
Required to drive your own vehicle for business purposes.