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Buena Vista Health & Recovery Centers UR Specialist I in Tucson, Arizona

Position Summary

Buena Vista Health and Recovery Centers is a growing, state of the art healthcare recovery center with multiple locations. We are currently seeking a Utilization Review Specialist to join our passionate team of healthcare professionals at our Tucson, AZ Campus.

Under general supervision, the Utilization Review Specialist reviews medical records of patients who are under treatment for substance abuse to ensure proper level of care placement, reviews patient records for proper case documentation, and medical necessity of treatment in relation to federal, state, county and payer regulation, assess continuing treatment plans, advocates for required patient treatment with medical providers, and performs other duties as required.

The Utilization Review Specialist will work Monday-Friday 8:00am-5:00pm.

Duties and Responsibilities

  • Reviews assigned caseload including admissions, continued stay, and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes

  • Facilitates clinical pertinence reviews on all patient admissions, continued stays, retrospective reviews, and denials

  • Handles all aspects of Utilization Review, including timely and accurate records, by obtaining the patient?s insurance authorization for prompt payment/reimbursement for assigned case load

  • Works directly with insurance companies, managed care organizations, and facility staff to ensure all crucial medical and clinical evidence of medical necessity has been communicated

  • Serves as a member of the multi-disciplinary team supporting the treatment program and assure the delivery of quality treatment to patients and their family members

  • Works independently and in collaboration with the UR Director and other members of the clinical and management staff

  • Utilizes organizational skills, proper phone etiquette and communication skills while pursuing timely insurance authorizations professionally but assertively

  • Self-directed and self-motivating, plans and conducts work with minimal direction, and reports the progress of work to the UR Director

  • Ensures patient confidentiality in compliance with 42CFR, Part 2 and Buena Vista?s privacy policies, procedures and practices as required by federal and state law in accordance with general principle of professionalism as a health care provider

  • May access protected health information (PHI) and other patient information only to the extent that is necessary to complete their assigned job functions and may only share such information with those who have a need to know specific patient information to complete their job functions/responsibilities

  • Interacts with fellow team members and patients in a respectful, professional manner.

  • Other duties as assigned

Minimum Qualifications

  • High School Diploma/GED

  • 1+ years? experience in a psychiatric, substance abuse or mental health setting

  • Communicate effectively in oral and written format

  • Maintain effective interpersonal relationships

  • Understand and apply state, federal, local and Payer regulations and laws governing quality assurance and utilization review

  • Ability to work independently and be self-motivated

  • Analyze clinical data, which include the diagnosis of client behavioral and emotional problems

  • Use good judgment in order to make critical decisions about the medical necessity of treatment

Preferred Qualifications

  • Bachelor?s Degree

  • Previous experience in utilization management with a broad range of experience with complex psychiatric/substance use cases

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