Job Summary: Under the administrative supervision of the Director of Utilization Management, the URC is responsible for the implementation, and maintenance of utilization review programs to facilitate the use of behavioral health resources and increasing timely requests and decreasing denials, increase client time in service and decrease loss of treatment. The URC shall operate in accordance with the policies set forth by the Board of Directors and shall abide by all applicable laws and regulations.

　　Submit for authorization, direct and monitor progress of clients thru for continuation of care, ensuring the timely and appropriate authorizations are obtained.

　　Mental health and substance abuse problems according to clinical information given by counselors and/or directors and internal criteria for medical necessity and appropriateness of care.

　　Work closely with the billing department to ensure ICD 10/DSM5 and CPT codes are accurate and input.

　　Ensure compliance with all performance measures regarding appeals, denials, higher level of care admission certification and concurrent review timeliness.

　　Compile and report daily review activity and facility statistics.

　　Work with Administrative Assistants to verify subscriber eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment and coordination of benefits prior to obtaining authorization for treatment.

　　Coordinate with counselors to ensure proper documentation completed for submission to obtain authorizations and continued care authorizations.

　　Track benefit usage and advise appropriate parties of exhaustion of benefits.

　　Anticipates and troubleshoots claim and reimbursement issues.

　　Interacts with third party payers to ensure coverage payment for patient care services provided.

　　Collects and monitors resource utilization data.

　　Actively participates with team meetings to discuss any issues related to utilization review processes or delays.

　　Participates in team meetings and actively takes part in clinical case discussions.

　　Acts as liaison with third party insurers as appropriate to facilitate resolution of medical necessity determinations and fiscal denials. Coordinates issuance of notices in accordance with state and federal regulations and departmental guidelines.

　　Other duties as requested by the Director of Utilization Management.

　　Qualifications

　　High School diploma or equivalent required. Bachelors degree preferred.

　　A minimum of two (2) years experience in health care settings including utilization review, behavioral health and/or substance use preferred.

　　Working knowledge of utilization review procedures and network providers. Behavioral health and Substance Use community resources knowledge preferred.

　　Possesses demonstrated knowledge and understanding of relevant utilization and laws, rules, regulations, and reimbursement regarding managed care, commercial, federal, and state government programs such as Medicaid and Medicare.

　　Ability to understand, interpret and analyze program evaluation data and design.

　　Exceptional interpersonal skills required as well as ability to communicate effectively both verbally and in writing.

　　Must be adaptable to change and have effective organizational skills.

　　Attention to detail required.

　　Must be able to work in collaboration with all members of the Mirror team.

　　Must be able to pass required security screening.

　　Employees who have been diagnosed with any type of substance use disorder or behavioral addiction/compulsion must have sustained a minimum of two consecutive years of abstinence from all intoxicating substances and symptoms of their chemical and/or behavioral addiction; and must be in full sustained remission.

　　Must be proficient in basic computer skills.

　　Experience with EHR software required.

　　Physical requirements would include but not limited to standing, walking, talking, hearing, and lifting (40/50 pounds). Walking stairs may be required as well.

　　Ability to travel 15% of the time.