Immersive Recovery is currently seeking a meticulous and knowledgeable Utilization Review Specialist to join our team. As the Utilization Review Specialist, you will play a pivotal role in ensuring that our clients receive the appropriate level of care and that all services are aligned with regulatory and payer guidelines.

Key Duties and Responsibilities:

Utilization Review: Conduct utilization reviews to assess the appropriateness and necessity of treatment services and coordinate with the clinical team to ensure clients' needs are met.

Insurance Verification: Verify clients' insurance coverage, benefits, and authorization requirements, obtaining necessary authorizations for services.

Clinical Documentation: Review and analyze client records, treatment plans, and progress notes to ensure accuracy, completeness, and compliance with regulatory and payer requirements.

Appeals and Denials: Assist in the appeal process for denied claims, working with insurance companies to provide additional information and documentation as needed.

Billing and Coding: Collaborate with billing and coding staff to ensure accurate and compliant submission of claims to insurance providers.

Policy Compliance: Stay informed about changes in insurance policies, regulations, and industry standards related to addiction treatment and utilization review.

Communication: Communicate with clients, clinical staff, and insurance companies regarding authorization status, appeals, and any other utilization review matters.

Data Analysis: Utilize data and outcomes measurement to assess and improve utilization review processes and outcomes.

Compliance Reporting: Prepare and submit required compliance reports to regulatory agencies and management, summarizing findings and recommendations for improvement.

Qualifications:

• Bachelor's degree in healthcare administration, nursing, psychology, or a related field (Master's degree preferred).
• Minimum of 3-5 years of experience in utilization review in the healthcare or addiction treatment field.
• Knowledge of insurance verification, billing, and coding processes.
• Exceptional attention to detail and analytical skills.
• Strong communication and interpersonal abilities.
• Proficiency in using electronic health record (EHR) systems.
• Commitment to maintaining the highest ethical standards and client confidentiality.