[Hiring] Utilization Review Specialist @Medusind

Role Description

The UR Representative is responsible for conducting Utilization Reviews (UR) to ensure appropriate authorization for behavioral health services. This role involves:

• Reviewing cases via multiple platforms
• Coordinating peer reviews
• Entering authorization data
• Following up on approvals
• Maintaining clear communication with facilities

Strong knowledge of levels of care, prior authorization processes, and behavioral health policies is required.

Qualifications

• Active and unrestricted Licensed Practical Nurse (LPN) credential
• Minimum of 2 years of Behavioral Health Clinical, Utilization Review, case management, or prior authorization experience preferred
• Knowledge of insurance authorization processes, levels of care, and medical necessity criteria
• Excellent verbal and written communication for facility interactions
• High level of accuracy, strong organizational, follow-up, and documentation skills
• Proficiency in EMR systems, Salesforce, and other workflow platforms
• Ability to prioritize tasks and manage multiple authorization cases simultaneously

Requirements

• Lead training for new onshore Reps and oversee development of payer-specific training materials
• Conduct CDI and documentation standardization training across customers to improve quality and compliance
• Partner with QA to perform ongoing UR audits and monitor accuracy trends
• Provide educational feedback to facilities on what supporting documentation is required to support authorization approvals
• Support knowledge transfer to Cognizant Training Leads and ensure timely dissemination of new payer/process updates
• Conduct Admin, Concurrent Utilization and Retro Reviews via:
  • Live Reviews
  • Voicemail Reviews
  • Fax Reviews
  • Portal Reviews
• Coordinate Peer Reviews as needed
• Provide Assignment of Responsibility (AOR) form templates at admission if required by the facility
• Enter UR authorization information into the facility's EMR billing system and internal workflow systems
• Ensure follow-ups on pending authorizations to secure required approvals and documentation
• Accurately document and track all UR activities in Salesforce and other designated systems
• Assist with document retrieval from EMRs when necessary
• Act as a liaison between the facility and internal teams
• Send morning and end-of-day emails to facilities with status updates
• Provide weekly email summaries to keep stakeholders informed
• Maintain a strong understanding of levels of care, insurance authorization requirements, and behavioral health regulations
• Identify and address gaps in documentation that could impact authorization approvals
• Review clinical documentation with a licensed nursing perspective to identify clinical charting deficiencies
• Ensure all UR requests for Authorization comply with relevant policies and payer requirements
• Assist in providing information/training to facility to ensure compliance
• Assist with other tasks that align with UR and prior authorization responsibilities as needed

Company Description