Utilization Review Specialist Behavioral Health
About UsNewport Academy is a series of evidence-based healing centers for adolescents and families struggling with mental health issues. With locations across the United States, Newport Academy offers a family-systems approach, providing gender-specific, individualized, and comprehensive holistic programs that encompass clinical therapy, academic support, and experiential practices. We treat individuals, ages 1220, who are experiencing depression, anxiety, eating disorders, trauma, and substance abuse. Offerings include residential treatment, intensive outpatient programming, therapeutic day schools, and day treatment. Newport Academy nurtures the physical, psychological, social, educational, and spiritual needs of adolescents and their families, from a foundation of compassionate care, clinical expertise, and unconditional love. Our primary mission is to empower teens and restore families. Experts include medical directors, psychiatrists, therapists, registered dietitians, nurses, licensed social workers, teachers, and more.
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Empowering Teens. Restoring Families.
ResponsibilitiesUnder the direction of the Manager/Director of Utilization Review, the Utilization Review Specialist is responsible for managing an active caseload of clients at the following Levels of Care: Detox, Residential, Partial Hospitalization, and Intensive Outpatient. S/he acts a liaison between insurance companies, the client, the clients family, and the Clinical Team. The Utilization Review Specialist is responsible for gathering required information, effectively case-building, and collaborating consistently with members of both the Utilization Review Team and interdisciplinary Treatment Team to ensure optimization of each clients coverage and benefits. S/he is responsible for communicating updates to appropriate representatives at the insurance company, the Clinical Team, and the clients family as directed by the Manager/Director of Utilization Review.
Essential Duties and Responsibilities:
- Complete Initial, concurrent, Peer, and retrospective reviews in a timely manner to ensure continuous coverage.
- Utilize clinical information and knowledge of Medical Necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.
- Conduct and manage initial, concurrent, and discharge reviews to optimize benefits and utilization.
- Represents the UR Department in a professional and positive way to other Departments and the company as a whole.
- Consistently demonstrate excellent communication, prioritization, and multi-tasking skills.
- Maintains contact with the clients families and keep them updated on current insurance authorization updates, Peer Reviews, and Denials.
- Document all activities in a detailed manner in applicable CRM/EMR.
- Collaborate with Clinicians and the multidisciplinary team daily at both the Residential and Day Programs in order to obtain necessary clinical documentation for reviews and ensure effective utilization of resources.
- Participate in weekly Treatment Team and Continuing Care Meetings as appropriate.
- Prepares and submit Appeal documentation (including rationales) to the appropriate entities as indicated
- Coordinate, schedule, and complete Peer-to-Peer and Appeal reviews.
- Complete weekly Treatment Team notes and provide updates to the Psychiatrist as requested by the Director/Manager.
- Follow chain of command both within the Department and outside of the Department.
- At least 2 years of work experience in the behavioral health field.
- Active license or credential in a behavioral health field (Preferred).
- Bachelors or Masters (Preferred) in a behavioral health related specialty.