Elements Behavioral Health Utilization Review Coordinator in Houston, Texas
The Coordinator of Utilization Review applies expertise of payor behavior and clinical guidelines to optimize utilization review (UR) outcomes. The Coordinator analyzes factors that result in denials to identify opportunities for improvement through collaboration with facility partners.
- Prescreens referrals to anticipate authorizations and provides recommendations regarding level of care, services and treatment planning.
- Collaborates with clinical team and prepare and present complex requests to the payor for determination of level of care and rapid readmissions.
- Coordinates and documents all concurrent insurance reviews with clinicians and medical team and provides any notices for missing documentation.
- Reviews medical records for quality clinical documentation and compliance and provides feedback to licensing, accrediting, and payor requirements
- Conducts live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and/or American Society of Addition Medicine (ASAM) to compel authorization.
- Negotiates clinical authorization outcomes with the payor, collaborating in advance with the primary treating clinicians.
- Coordinates, provides guidance and assists with scheduling for Peer-to-Peer (P2P) review preparation.
- Establishes internal authorization or denial for No Authorization Required (NAR) requests and establishes post denial appeal response recommendations.
- Ensures timely and accurate UR responses for daily report
- Coordinates with Admissions and Verification of Benefit (VOB) team for expected insurance contribution for continued stay.
- Maintains billing information based on census boards and communicates to relevant parties at the facility and the Central Billing Office (CBO) any issues with coverage or denials, billing issues and facilitates client notifications as needed.
- Attends and participates in Treatment Team Meetings as the payor expert to ensure appropriate authorization outcomes and provide ongoing education regarding payor requirements
- Completes Denial Notification process and assists Financial Advisors with explanation to the client or family regarding the denial.
- Senior Coordinator of UR includes managing projects, assisting with UR auditing, and assisting with providing staff trainings related to UR activities
- Licensed Masters Level in Behavioral Health, licensed chemical dependency counselor (LADAC or LCDC), or RN OR three (3) years behavioral health experience working directly with clients plus one year in utilization review experience.
- Experience in a behavioral health setting with a combination of direct clinical and UR experience preferred.
- Strong knowledge payor medical necessity guidelines and ASAM.Ability to analyze medical records documentation and apply criteria and guidelines.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled