Utilization & Review Specialist (Abingdon)

Crossroads Treatment Centers - Abingdon, VA2.6

Full-timeEstimated: $47,000 - $63,000 a year
Position Summary:This position is responsible for activities related to authorization and maintenance of therapy service related to insurance benefits and compliance monitoring of billable activities.

Essential Duties and Responsibilities:include the following and other duties that are assigned.

Works closely with Clinical Director, Program Director, Regional Director and Medicaid Specialist and clinical staff towards compliance monitoring
Uses Medicaid Payer existing metrics/tools to track clinical and documentation compliance including standards for care
Helps direct patients in the process for obtaining Medicaid insurance with the designated social service agency
Helps enroll patients with Medicaid Payer as needed to access and make changes to behavioral health benefits
Verifies benefits coverage for new and returning patients via State eligibility system
Responsible for submitting treatment authorizations for new intakes, transfers and re-admissions
Tracks authorization status including billable units remaining for timely subsequent re-authorizations
Works with Medicaid Payer and Clinical Director to address treatment outcomes for patients who do not meet continued stay criteria
Manages paperwork and communication related to requests for Medicaid Payer for step-up/step-down transitions between levels of care
Enters patient “flags” in medical record in advance of required counseling and doctor appointments within the first 30 days of treatment in additional to “flags” for
weekly nurse documentation requirement
Clinical experience and behavioral health counselor credentials preferred
Requires high proficiency for technology, problem solving and attention to detail
Advises Program Director(s) surrounding trends in UR, inefficiencies, unethical practices, etc.
Assists with the compilation of monthly financial report for CTC accounting team
Helps to collect data and create reports for overpayments
Monitors monthly Medicaid Eligibility of existing clients on the first of each month
Manually enters claims and remits to and from Method One as needed
Helps connect Medicaid patients to services such as transportation to support their treatment
Maintains updates and changes to Method One data related to billable services
Ensures that all billable services including weekly nursing note have been documented prior to submitting claims
Assists the Clinical Director to audit service documentation for clinicians, physician, nursing staff to ensure accuracy of billable services
Performs daily audit of charges against clinician documentation and addresses discrepancies and errors
Helps patients navigate circumstances related to the benefits utilization
Interfaces with billing contractor who serves as the direct point of contact with clearinghouse and Medicaid Payer around claims, remittance, denial and appeal

Qualification Requirements:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Position requires constant mental alertness, attention to detail and high degree of accuracy in completing all assignments. Must be able to follow oral and written instructions and follow-through on all assignments. If recovering, three years of continuous verifiable abstinence is required.

Education and/or Experience:High School Diploma or equivalent is required.

Language Skills:Ability to read, analyze and interpret human service periodicals, professional journals, technical procedures or governmental regulations. Ability to write reports, business correspondence and procedure manuals. Ability to effectively present


Crossroads Treatment Centers does not discriminate on the basis of race, sex, color, religion, age, national origin, marital status, disability, veteran status, genetic information, sexual orientation, gender identity or any other reason prohibited by law in provision of employment opportunities and benefits.