Utilization Review Specialist - Woods Services
Langhorne, PA 19047
About the Job
We want you to join our team! We need deeply compassionate, committed, and highly talented staff. The Woods organization is guided by their mission to support children and adults with disabilities or challenges to achieve their highest potential and independence through innovative and individualized approaches that promote learning and personal fulfillment.
Benefits
- Medical, Dental, Vision Insurance
- Life and Disability Insurance
- PTO - Paid time off
- On-site FREE medical center
- 403b retirement plan
- Continuing education programs
- Tuition assisted program
- Career growth opportunities
Salary: Starting salary $50000 / Annually depending upon education and experience
Job Summary
The Utilization Review Specialist will examine medical and behavioral health insurance benefits to ensure proper coverage, address lapses in coverage, manage authorization process, billing process, decipher complicated insurance laws and policies including Medicare, Medicaid, Behavioral Health Coverage, and Commercial Health Insurance Coverage.
Responsibilities:- Manages pre-authorization and review process for commercial and managed health care providers including identification of contacts and contract procedures and packet submissions.
- Develops and maintains contracts with health care providers including adherence to all policies and procedures to enroll as a provider and maintain enrollment.
- Works directly with Contract Administrators on managed and commercial insurance contracts and single case agreements.
- Works directly with families, guardians, and agencies to ensure proper insurance coverage, coordination of benefits, billing procedures, and disputes.
- Works directly with nursing department, care coordination department and finance department to ensure coverage is utilized, care is provided by proper providers, and that any accompanying bills/payments are managed.
- Acts as a liaison between insurance member, families, fiscal, residential, and providers
- Handles unique funding/authorization issues as needed.
- Schedules and conducts clinical meetings and ongoing ISP meetings as needed.
- May involve appeals and coordination of peer to peer reviews.
- In coordination with the treatment team, the UR specialist will be responsible for identification of community resources, coordinating transition and submitting funding packets for those lower levels of service.
- All other duties as assigned
- Must be able to lift 50 pounds.
- Bachelor’s Degree in Social Work or related field with five or more years of experience with insurance verification, managed & commercial health plan procedures, and/or contract compliance.
- Master’s degree preferred.
- Experience working with commercial and managed health care benefits
- Experience with pre-authorization and review process for continued stay
- Ability and knowledge of contracting for services
- Knowledge of commercial and public health benefits and membership qualifications
- Coordination of Benefits
- Ability to work with agencies and families to ensure, apply for, and dispute coverage
- Comprehensive understanding of insurance-based terminology and coding
- Computer, communications, analytical, and comprehension skills
- Travel required.
About Woods Services
Woods Services is a Pennsylvania and New Jersey-based non-profit population health network and advocacy organization that along with its six affiliate organizations provides life-long innovative, comprehensive, and integrated health, education, housing, workforce, behavioral health, and case management services to more than 22,000 children and adults in the intellectual and developmental disability, child welfare, behavioral and brain trauma public health sectors who have complex and intensive medical and behavioral healthcare needs.
Our Langhorne campus is home to 550 residents and provides outpatient and day programs.