Utilization Review Representative

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),