Utilization Review Specialist - Sanctuary Recovery Centers

The UR Authorization (Auth) Coordinator is the key position for reviewing admissions and utilization authorizations throughout Sanctuary facilities. The UR Auth Coordinator is responsible for reviewing clinical documentation, communicating with various sites, and securing and processing authorizations for inpatient, residential, and all other services that request payor authorization. The UR Auth Coordinator secures and monitors pre-certifications, concurrent reviews, retro reviews, and appeals to ensure that the members are getting timely, appropriate care. The UR Auth Coordinator serves as a communication liaison between Sanctuary Recovery Centers and the assigned payors. The UR Auth Coordinator will continue to seek knowledge of the industry, assigned payors, and maintain a strong knowledge of the overall departmental and organization functions.

Process and Practice Development

• Responsible for making recommendations for process improvements and report any barriers experienced by the UM department.
• Responsible for coordination of the flow of patients from medical management teams, completes referral in the EMR, collects medical records for completeness, identifies availability of appropriate bed placements and ensures timely review for acceptance/notification of denials.
• Ensures all coordination of care & authorizations are documented accordingly prior to departure of each shift.
• Responsible for maintaining call logs, productivity reports and status reports.
• Attends weekly staff meetings and at least one UM Team meeting per month in person.
• Protects each patient's confidentiality within the parameters of federal guidelines and established policy and process.
• Adheres to established policy and process for this assignment.
• Other duties as assigned by supervisory and administrative support.

Pre-certification of Services (Authorizations)

• Responsible for ensuring that Sanctuary Recovery Center's has obtained authorization for medically necessary services provided to patients.
• Ensures Notice of Admissions are submitted as appropriate within the required timelines of the payors.
• Reviews admissions daily for each assigned program to ensure that any pre-certification is completed appropriately.
• Reviews bed board daily to ensure that length of stay for each program is within authorized duration. Additionally, provides notice to program management and staff regarding upcoming and overdue authorization expirations.
• Prior Authorization (PA) forms by payor are completed by appropriate medical staff, and submission to the respective payors of services within the required timelines established by that payor.
• Provides educational support to staff on admission criteria for each level of care that incorporate medical criteria to meet each of the contracted payors and private insurance standards.
• Requests retro reviews from Medical Records and mails them to the requesting payors.
• Documents each mailed out retro review and complete follow up to ensure review was received by appropriate party and authorization is obtained.
• Pulls admit/discharge report daily and verifies all private insurance admits had insurance verified and authorization obtained.
• Completes daily spreadsheet that lists private insurance admits and what follow up is still needed.
• Ensures each authorization obtained and status of any pending authorizations is documented in EMR.

Skills/Requirements

• High School diploma or GED required. Associates Degree (or higher) in a field related to Business or Health Care preferred.
• 3 or more years of administrative work history, such as front office, secretary and/or clerical preferred.
• 1 or more years of experience in healthcare setting preferred.
• Or equivalent combination of education and experience