Utilization Review Representative

About Zealie

Zealie is a fast-growing Medical Billing Services company specializing in the Behavioral Healthcare industry. Our clients are substance use disorder treatment, addiction recovery, and mental health treatment centers that are saving lives on a daily basis. Our state of the art proprietary technology provides data analytics and revenue prediction tools to our clients to help them make strategic business decisions to grow their business. We are committed to delivering exceptional products and services to our clients and believe that our Utilization Review team plays a crucial role in achieving this mission.

Overview

The Utilization Review (UR) Representative is responsible for the management and coordination of authorization processes, ensuring compliance with insurance and regulatory requirements while advocating for optimal patient care. This role involves advanced responsibilities, including oversight of UR processes and direct collaboration with clinical teams and insurance providers. The successful candidate is expected to exhibit deep expertise in navigating electronic medical records, conducting peer reviews, and managing complex cases, all while maintaining strict adherence to compliance standards and HIPAA regulations.

Key Responsibilities:

• Lead and Oversee Authorization Processes: Direct and manage the authorization processes for assigned facilities, ensuring all authorizations are obtained in a timely manner while adhering to the organization's UR protocols.
• Advanced Case Management: Handle complex cases that require a higher level of expertise in medical necessity and insurance protocols, including managing appeals and retro authorization processes.
• Collaboration with Clinical Teams: Work closely with facility treatment teams to coordinate the level of care for patients, ensuring that services are appropriately authorized and documented.
• Peer Review Facilitation: Coordinate and conduct peer reviews or facilitate scheduling as required, providing critical analysis of cases to determine medical necessity.
• Documentation and Compliance: Maintain comprehensive and accurate documentation of all authorization-related activities, including days authorized, next review dates, and communication logs, ensuring compliance with all regulatory requirements.
• Patient Advocacy: Advocate on behalf of patients to ensure that 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 both facilities and insurance providers, ensuring a smooth transition for patients.
• Utilize Advanced Technology Tools: Efficiently use and train others on industry-specific software and tools such as Kipu, ZenCharts, BestNotes, and SunWave, along with proficiency in Google Workspace.
• Process Improvement: Identify areas for process improvement within the UR function, recommending and implementing changes to enhance efficiency and effectiveness.

Qualifications

Experience:

• 6-10 years of experience in the Utilization Review process, with demonstrated expertise in handling complex cases.
• At least 4 years of experience in Substance Abuse/Mental Health Treatment, with deep knowledge of ASAM criteria and medical necessity standards.
• Extensive experience in managing clinical appeals and navigating private insurance requirements for appeals and authorizations.

Education:

• Bachelor’s degree or higher in Psychology, Behavioral Health, or a related field is required.
• Licensed Mental Health Clinician (LCSW, LMHC, LMFT) or Certified Addiction Counselor/Professional (CAC, CAP, MCAP, MAC) is highly preferred.

Skills:

• Advanced proficiency in electronic medical record systems and related UR software (e.g., Kipu, ZenCharts, BestNotes, SunWave).
• Strong leadership and mentorship capabilities, with proven experience in guiding junior staff.
• Excellent verbal and written communication skills, with the ability to articulate complex medical necessity criteria and advocate for patient care.
• Exceptional organizational skills, with the ability to manage multiple cases and priorities effectively.
• In-depth knowledge of all levels of care within psychiatric and behavioral healthcare settings, including Detox, RTC, PHP, IOP, OP, and Aftercare.
• Experience managing caseloads of 40+ cases per week, with a track record of obtaining a high volume of authorizations.
• Experience in a behavioral health billing setting, with a thorough understanding of day-to-day operations in psychiatric or behavioral healthcare facilities.

Additional Preferred Experience

• Experience managing caseloads of 40+ cases per week, with a track record of obtaining a high volume of authorizations.
• Experience in a behavioral health billing setting, with a thorough understanding of day-to-day operations in psychiatric or behavioral healthcare facilities.

The UR Representative role is integral to ensuring that patients receive the necessary care while navigating the complexities of insurance authorization processes. This position requires a high level of expertise and a commitment to advocating for patient well-being within the framework of compliance and regulatory standards.

Apply today if this sounds like you!

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)