*Job Title: *Utilization Management Specialist

　　*Location: *Bountiful, UT

　　Full-Time

　　The Purpose of Your Role

　　The UM specialist is an advocate who works with clients and commercial insurance payors to obtain approval for proper treatment services. They promote quality, cost-effective care strategies to payers using evidence-based criteria to meet the care guidelines. They are the company's connection between health care providers, clients, and insurance companies. After the provider determines the appropriate level of care during the intake, the UM specialist works with the client through the full approval cycle to help the payor identify medical necessity, appropriateness, and reasonableness of services recommended by the provider. They have a thorough knowledge of payer policies, guidelines, appeals, corrected/voided claim submission, and up-to-date on all-payer changes.

　　The UM specialist demonstrates excellent customer service skills and communicates professionally and effectively.

　　The UM specialist required effective communication and coordination with the Director of Utilization Management, with fellow UM specialists, insurance companies, and the treatment team to obtain the maximum benefit for our clients. The position entails coordinating and managing concurrent and retrospective reviews of all client's medical records over the continuum of care. The UM specialist is responsible for completing admission, concurrent and peer reviews as well as initiating denials and appeals. The UM specialist ensures cases are reviewed and responded to in a timely and clinically sound manner in accordance with policies and procedures.

　　Objectives:

　　Completes pre-authorizations/concurrent reviews/discharge and peer reviews.Applies utilization criteria to monitor the appropriateness of admissions with associated levels of care and continued stay review.Communicates with commercial and third-party payers for initial and concurrent clinical reviews.Document actions and information shared with the treatment team or third-party payers.Review clinical documentation in charts to prepare for each review and ensure charts are aligned with insurance company guidelines.```{=html}

　　```- Collect data on variances in LOC, lost days, cost/barriers to discharge and denied days.- Schedules and completes peer-to-peer reviews and coordinates crucial appeals.- Initiate single-case agreements and work collaboratively with payer relations team to execute rates and secure authorization.- Reviews clinical documentation.- Review the quality of documentation provided to assure adequacy and clinical appropriateness for current LOC.- Coordinates with the treatment team, billing, and clients to obtain proper documentation and authorizations- Coordinates benefits and transition between various levels of care.- Communicates all UM related information with the treatment team to share updates with clients and families regarding the status of current authorization.- Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem-solving actions.

　　Required:

　　High school diploma or equivalent2+ years experience in customer service, billing, or utilization reviewFamiliarity with medical terminology and medical billing practicesProficient knowledge of computers, including Microsoft Word, Excel, and other computer softwareAccurate and efficient electronic data entryMust be punctual and maintain excellent attendanceOrganized, detail-oriented, takes initiative, and completes job responsibilities independentlyMultitask, problem-solve, interpersonal skills, and strong written and verbal communication skills maintain confidentiality and trustworthinessPhysical demands of the job include sitting at a desk or table for extended periods, bending, lifting, nd walkingPass a full criminal background checkEligible to work in the USPreferred Qualifications:

　　Proven experience as a billing coordinator or similar positionActive SUDC, ASUDC, CSW, LCSW, CMHC, ACMHC, RN, or LPN licenseWorking knowledge of EMR softwareTeam management and leadership skills