Job Description
Description Clinical Utilization Review Specialist
Lauderdale Lakes, FL About Exact Billing Solutions Exact Billing Solutions is a unique team of medical billing professionals specializing in the substance use disorder, mental health, and autism fields of healthcare services. We have extensive industry knowledge, a deep understanding of the specific challenges of these markets, and a reputation for innovation. With our proprietary billing process, EBS is the oil that brings life to the engines of its partner healthcare companies.
Growth Opportunity in Cutting-Edge Medical Billing If you're an experienced clinician looking to forge a new career path where your clinical knowledge is valued, consider our Clinical Utilization Review Specialist position.
As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources. You will be responsible for reviewing and evaluating clinical documentation, treatment plans, and medical records to optimize patient care and streamline healthcare delivery processes. Ideal candidates will possess a clinical background, and preference will be given to individuals with specialized expertise, for example, BCBA (Board Certified Behavior Analyst), LSW (Licensed Social Worker), PT (Physical Therapist).
What You Will Do Clinical Documentation Review: - Evaluate and analyze medical records, treatment plans, and clinical documentation to ensure accuracy and compliance with established standards.
- Collaborate with healthcare providers to gather additional information or clarification on documentation when necessary.
- Live reviews with BSBAs and other health professionals
Utilization Review: - Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies.
- Identify and communicate potential issues related to overutilization or underutilization of services.
Collaboration and Communication: - Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews.
- Communicate findings and recommendations clearly and effectively to internal teams and external stakeholders.
Quality Improvement: - Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery.
- Provide feedback and suggestions for process improvements based on review findings.
Regulatory Compliance: - Stay informed on relevant healthcare regulations, guidelines, and accreditation standards.
- Ensure compliance with all applicable laws and regulations in the utilization review process.
Requirements Experience and Requirements - Knowledge and ability to communicate medical necessity using medical dialect.
- Complete assessments, pre-certifications, initial authorizations, re-authorization, peer reviews and appeals.
- Initiate, prepare and resolve appeals.
- Ensure EMR is up to date and accurate in regards to UR
- Advocate on the client(s) behalf to ensure services will be covered by insurance company.
- Work closely with clinical team to ensure continuity and quality of care for clients
- Knowledge in ABA guidelines and criteria to identify and advocate for appropriate care placement
- Monitor clinical documentation to insure appropriate, timely and effective provision of services and treatment planning.
- Ensure that all insurance information needed for billing and collection processes are obtained and recorded appropriately in the EMR system
- Ability to adhere to HIPPA compliance standards
ICBD Holdings LLC
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