2 Utilization Review Jobs

Role Overview: Zealie, a fast-growing Medical Billing Services company specializing in the Behavioral Healthcare industry, is seeking a Utilization Review (UR) Representative to play a crucial role in managing and coordinating authorization processes while ensuring compliance with insurance and regulatory requirements. The successful candidate will work closely with clinical teams and insurance providers to advocate for optimal patient care through advanced responsibilities and adherence to strict compliance standards and HIPAA regulations. Key Responsibilities: - Lead and Oversee Authorization Processes: Direct and manage authorization processes for assigned facilities, ensuring timely acquisition of all authorizations while following the organization's UR protocols. - Advanced Case Management: Handle complex cases requiring expertise in medical necessity and insurance protocols, including managing appeals and retro authorization processes. - Collaboration with Clinical Teams: Coordinate the level of care for patients with facility treatment teams to ensure appropriate services are authorized and documented. - Peer Review Facilitation: Coordinate and conduct peer reviews as needed, providing critical analysis to determine medical necessity. - Documentation and Compliance: Maintain comprehensive documentation of all authorization-related activities, ensuring compliance with regulatory requirements. - Patient Advocacy: Advocate for patients to ensure necessary services are covered by insurance, utilizing advanced knowledge of medical necessity criteria and insurance policies. - Discharge Coordination: Provide discharge referrals and necessary information to facilities and insurance providers for a smooth patient transition. - Utilize Advanced Technology Tools: Efficiently use industry-specific software and tools and train others as necessary. - Process Improvement: Identify areas for process enhancement within the UR function and implement changes to improve efficiency. Qualifications: Experience: - 6-10 years of Utilization Review experience, with expertise in handling complex cases. - At least 4 years of Substance Abuse/Mental Health Treatment experience, with knowledge of ASAM criteria and medical necessity standards. - Extensive experience in managing clinical appeals and navigating private insurance requirements. Education: - Bachelor's degree or higher in Psychology, Behavioral Health, or related field. - Preferred: Licensed Mental Health Clinician or Certified Addiction Counselor/Professional. Skills: - Proficiency in electronic medical record systems and UR software. - Strong leadership and mentorship abilities. - Excellent communication skills. - Exceptional organizational skills. - In-depth knowledge of psychiatric and behavioral healthcare settings. - Experience managing high caseloads and authorizations. - Understanding of behavioral health billing operations. Additional Company Details: The UR Representative role at Zealie is crucial for ensuring patients receive necessary care while navigating insurance authorization processes. This position requires expertise and a commitment to patient well-being within compliance and regulatory standards. Apply today if this opportunity aligns with your skill set and experience! Job Type: Full-time Expected Hours: 40 per week Benefits: - Health insurance - Paid sick time - Paid time off - Provident Fund - Work from home Education: Bachelor's (Preferred),

As a Medical Claims Review Senior Analyst/Clinical Supervisor in the Complex Claim Unit, you will provide clinical review expertise for high dollar and complex claims, including facility and professional bills. Your role includes identifying coding and billing errors, ensuring the application of Medical and Reimbursement Policies for cost containment, and identifying cases for potential fraud and abuse. Your major responsibilities will involve evaluating medical information against criteria, benefit plans, and coverage policies to determine the necessity for procedures. In cases where criteria are not met, you will refer to the Medical Director. You will also evaluate itemized bills against reimbursement policies, adhere to quality assurance standards, and serve as a resource to facilitate understanding of products. Handling some escalated cases and advising supervisory staff on concerns or complaints expressed by Health Care Professionals will be part of your duties. Furthermore, you will participate in special projects, perform random or focused reviews as required, support training and precepting, analyze clinical information, and focus on coding and billing errors during claim reviews. Identifying and referring cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners will be crucial. You will also handle multiple products and benefit plans while working under moderate direct supervision. To qualify for this role, you should be a Dental Graduate/BDS/MDS with active Medical maintenance as required by state and company guidelines. Clinical experience in hospitals/clinics for 3 or more years is essential. Being a team player with flexibility, adaptability, excellent time management, organizational, and research skills is necessary. Experience with MS Office Suite is preferred. Preferred qualifications include Utilization Review or Claim Review experience in Health insurance and knowledge of the Principles of Health Care Reimbursement. Key skills and competencies for success in this role include a strong background in quantitative decision-making, ability to drive business/operations metrics, good communication, strong interpersonal skills, organization, and proactive time management. Exposure to a global work environment and meeting tight timelines are also important in this position. Join Cigna Healthcare, a division of The Cigna Group, and be part of advocating for better health through every stage of life. Empower customers with the information they need to make the best choices for improving their health and vitality. Be a part of driving growth and improving lives.,