Position title
Utilization Reviewer
Description
The Utilization Reviewer is in charge of reviewing and assessing the medical necessity, appropriateness, and effectiveness of behavioral health treatments. This job ensures that patients receive the appropriate degree of treatment at the appropriate time while complying to organizational rules, healthcare regulations, and industry guidelines. The position requires advanced clinical skills and experience in behavioral health settings, with a focus on managed care, case management, and utilization review.
Responsibilities
- Conduct utilization reviews for behavioral health services, ensuring that the care provided aligns with medical necessity and is appropriate for the patient’s condition.
- Collaborate with healthcare providers to ensure efficient and effective delivery of behavioral health services.
- Apply clinical judgment to evaluate patient needs and ensure treatment plans are aligned with current evidence-based practices and managed care protocols.
- Collaborate with interdisciplinary teams, including behavioral health specialists and primary care providers, to coordinate care across various settings.
- Ensure smooth transitions of care for patients requiring different levels of behavioral health services, such as inpatient to outpatient care.
- Ensure documentation is completed accurately and complies with regulatory and organizational standards.
- Utilize electronic medical record systems such as EPIC and Clinical Care Advanced for documentation and reporting purposes.
- Stay up-to-date with state and federal regulations regarding behavioral health and managed care.
- Serve as a liaison between the organization, providers, patients, and insurers to facilitate communication about care decisions and benefit utilization.
- Address patient, provider, and family concerns regarding treatment plans and service coverage.
- Maintain knowledge of industry trends, best practices, and regulations in behavioral health, case management, and utilization management.
- Obtain Case Management Certification (CCM) or Utilization Management Certification (MCG) within two (2) years of hire.
- Be open to accepting new challenges and tasks as they arise.
Qualifications
- Excellent communication and interpersonal skills.
- Master’s degree in Mental Health, Social Work, Clinical Psychology, or a closely related field is required.
- Must hold a current, unencumbered Oregon credential/licensure in one (1) of the following:
- Licensed Clinical Social Worker (LCSW)
- Licensed Professional Counselor (LPC)
- Licensed Psychologist (PhD or PsyD)
- Clinical Social Work Associate (CSWA)
- Licensed Master of Social Work (LMSW)
- Licensed Marriage and Family Therapist (LMFT)
- A minimum of two (2) years of clinical experience in behavioral health is required.
- Experience or training in healthcare delivery systems, especially within managed care settings.
- Proficiency with computer applications and electronic documentation, including MS Office, EPIC, and Clinical Care Advanced.
- Has an active certificate in Management Certification (CCM) or Utilization Management Certification (MCG) is required.
- Detail-oriented with strong organizational skills to manage multiple cases simultaneously.
- Familiarity with behavioral health regulations, managed care practices, and utilization review protocols.
- Knowledge of medical office procedures.
- Skill in operating a computer.
- Skill in answering the telephone in a pleasant and helpful manner.
- Ability to work under pressure and still maintain accuracy.
Hiring organization
Employment Type
Full-time
Job Location
Date posted
September 17, 2024
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