We save lives while providing the opportunity for people to realize their healthy selves.Utilization Review ClinicianMonte NidoRemoteMonte Nido has been delivering treatment for eating disorders for over two decades. Our programs offer a model of treatment that blends medically sophisticated care with a personalized treatment approach. Our work is grounded in evidence-based strategies for adults and adolescents suffering from eating disorders. We work from a multi-disciplinary treatment team approach while integrating state-of-the-art medical, psychiatric, nutritional, and clinical strategies to provide comprehensive care within an intimate home setting.We are seeking a Utilization Review Clinician to join our team. This is a fully remote role with working hours aligned to Eastern Time. Ideal candidates will be able to manage their schedules to meet the demands of this time zone, ensuring seamless collaboration with our team and stakeholders.The Utilization Review Clinician is responsible for conducting all utilization reviews, peer reviews, and pre-certifications in a well formulated and comprehensive manner, documenting these reviews, and coordinating with both the on-site clinical team, admissions, verifications, and billing regarding clients’ insurance status.Total Rewards:Discover a rewarding career with us and enjoy an array of comprehensive benefits! We prioritize your success and well-being, providing:
Competitive compensation
Medical, dental, and vision insurance coverage (Benefits At a Glance (https://montenidoaffiliates.icims.com/icims2/servlet/icims2?module=AppInert&action=download&id=2025&hashed=-1683222091) )
Retirement
Company-paid life insurance, AD&D, and short-term disability
Employee Assistance Program (EAP)
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Paid time off
Professional development
And many more!
We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.Responsibilities Include:
Complete prior authorizations for all levels of care, peer to peer reviews, Single Case Agreements, and manage denials through all levels of appeal for initial authorizations.
Expectation to provide prior authorization support and coverage across all Admission Hubs and UM Department staff as needed.
Responsible for supporting Admissions team members in understanding how payors determine medical necessity, documentation needs, auth process, and determination timeline to provide the highest level of advocacy and efficiency possible.
Bridge communication and care coordination between Admissions and UR team for increased understanding of potential barriers to authorization
Foster collaborative relationships with several departments including Admissions, MN UM, Revenue Cycle Management, and treatment programs.
Maintain up to date knowledge of all MN programs, treatment innovations, and research.
Apply understanding of payors medical necessity criteria in communications with payors
Complete timely and thorough documentation as required.
Coordinate with Leadership and other departments as needed to ensure highest quality of advocacy and access to care for our patients
Maintain up to date knowledge of payor & market trends, Medicaid and Medicare benefits, plan structure, and medical necessity criteria.
Contribute to data base of payor contacts, authorization process, requirements, and development of additional support tools.
Understanding of Medicare medical necessity criteria; consult with Admissions staff and Director of Utilization Management on all evaluations for Medicare members including level of care determinations.
Detailed and timely communication with leadership and all involved programs of authorization status.
Communicates emerging payor trends and changes to their authorization process to UM Department Leadership.
Qualifications:
Master’s degree from an accredited program in social work, clinical counseling, nursing, nutrition, or equivalent.
Independent State license or independent license eligible (LICSW, LMHC, LPC, Ph.D., RN, RD, LPN or equivalent active Independent Professional Licensure)
1+ years’ experience in behavioral health utilization review
2+ years’ experience providing direct clinical care in a mental health setting, preferably with eating disorders in higher levels of care
Knowledge of the Utilization review process which is to ensure that cases are formulated in a comprehensive manner, realistic goals are set, patient severity of illness indicators are objectively presented, and that treatment is provided at the most appropriate level of care. An understanding of severity of illness and intensity of service criteria for various levels of care. Familiarity with the utilization review requirements of Joint Commission, Medicare, Medicaid, and other third party payors.
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