JOB SUMMARY
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. This role is responsible 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

•  Make 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.
• Request clinical records from providers as needed to determine medical necessity. Perform telephonic consultations with providers as necessary to gain any additional clinical information or clarification needed to determine medical necessity of requested services.
• Review all potential denials and refers all medical necessity denials and out-of-network requests to Medical Director for final determination.
• Compose denial explanations in terms that are easy to understand and accurately reflect the clinical condition and reason services are not approved.
• Provide consultation and guidance to therapy providers related to service authorization, provision of speech, physical and occupational therapy services, and evidence-based practices.  Perform outreach to providers whose treatment requests indicate a trend that varies from clinical guidelines.
• Identify and refer at-risk members to internal and external case and disease management programs, as well as relevant community services and agencies, including recognition and appropriate reporting of any signs of abuse, neglect, or exploitation of a member in accordance with applicable law and company policy.
• Participate in quality initiatives, such as case reviews, claims review and analysis, interrater reliability testing, audits, and continuous process improvement.

BENEFITS
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%
• Tuition Reimbursement
• PTO accrual beginning Day 1

   Note: Benefits may vary based upon position type and/or level.

QUALIFICATIONS

• EDUCATION - Bachelor's
• EXPERIENCE - A minimum of 3 years experience required
• Lic Clinical Social Worker (LCSW), Lic Masters Social Worker (LMSW), Lic Master Social Wrk AdvPrac (LMSW-AP)> preferred

- 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.