The Utilization Review Specialist provides subject matter expertise in performing utilization reviews and educates health plan staff and providers regarding the appropriate delivery of therapy services. Accountable for development of utilization management criteria and policy in conjunction with the health plan Medical Director and Health Services leadership.
ESSENTIAL FUNCTIONS OF THE ROLE
Makes accurate, clinically appropriate, and consistent approval authorization determinations, including collecting appropriate clinical information, applying appropriate medical criteria, consulting with Medical Director, and communicating authorization determinations to providers, members or patients in accordance with policy and procedure and within timeliness requirements.
Requests clinical records from providers as needed to establish medical necessity. Performs telephonic consultations with providers as necessary to gain any additional clinical information or clarification needed to establish medical necessity of requested services.
Reviews all potential denials and refers all medical necessity denials and out-of-network requests to Medical Director for final determination.
Composes denial explanations in terms that are easy to know about and accurately reflect the clinical condition and reason services are not approved.
Provides consultation and guidance to therapy providers related to service authorization, provision of speech, physical and occupational therapy services, and evidence-based practices. Performs outreach to providers whose treatment requests indicate a trend that varies from clinical guidelines.
Proactively works to help appropriate utilization of benefits, including assisting with network management and assisting to ensure members are utilizing in-network providers whenever possible.
Identifies and refers at-risk members to internal and external case and disease management programs, as well as relevant community services and agencies. Includes recognition and appropriate reporting of any signs of abuse, neglect, or exploitation of a member in accordance with applicable law and company policy.
Participates in quality initiatives, such as case reviews, claims review and study, interrater reliability testing, audits, and continuous process improvement.
Partners effectively with internal and external clinical staff and leadership in the provision of services to members.
Maintains current knowledge of approved utilization management criteria, guidelines and regulations.
KEY SUCCESS FACTORS
Experience in managed care utilization management and/or similar setting with application of criteria to making authorization determinations highly preferred.
3 years of related clinical experience in outpatient, skilled subacute/skilled nursing facility, or home care settings.
Proficient with use of software applications in order to perform at expected pace of the position.
Our competitive benefits package includes the following
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelor's
- EXPERIENCE - 3 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION - Lic Bachelor Social Worker (LBSW), Lic Clinical Social Worker (LCSW), Lic Masters Social Worker (LMSW), Lic Master Social Wrk AdvPrac (LMSW-AP), Occupational Therapist (OT), Physical Therapist (PT), Speech Language Pathlogist (SLP): Must have one of the following PT, OT, SLP, LBSW, LCSW, LMSW, LMSW-AP.
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!