Utilization Reviewer II
 McLean Hospital | |
 United States, Massachusetts, Middleborough | |
| 23 Isaac Street (Show on map) | |
 Jan 14, 2025 | |
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Summary
Performs concurrent reviews of outpatient and in-patient claims and performs authorization reviews of patient services. Pursues receipt of high-quality medical outcomes for patients who require precertification/preauthorization. Does this position require Patient Care? Yes Essential Functions -Assesses, reviews, and assigns cases for utilization review (UR) -Assists with the negotiations of access to care in specified targeted areas; maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims. -Assist with negotiating reimbursement rates with third party payers -Prepares clinical information for each concurrent review directly from the medical record. -Protects healthcare organization value by keeping information confidential; cautioning others regarding potential breaches. -Facilitate effective communication between members of the treatment team -Maintains compliance with regulation changes affecting utilization management -Use appropriate screening criteria, knowledge and clinical judgment to assess patient needs. -Recognizes and reports appropriately cases of fraud, abuse or mis-utilization -Ensure quality and quantity of documentation in medical records for UR. Education Bachelor's Degree Related Field of Study required or Doctor of Physical Therapy Physical Therapy preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Licensed Clinical Social Worker [LCSW - State License] - Generic - HR Only preferred Social Worker [Licensed Independent Clinical Social Worker - LICSW - State License] - Generic - HR Only preferred Occupational Therapist [State License] - Generic - HR Only preferred Physical Therapist [State License] - Generic - HR Only preferred Registered Nurse [RN - State License] - Generic - HR Only preferred Licensed Mental Health Counselor [LMHC - State License] - Generic - HR Only preferred Experience clinical experience, including during training, working with Rehab, psychiatric in-patient population 2-3 years preferred Knowledge, Skills and Abilities - Broad knowledge of various insurances and government reimbursements. - Excellent analytical and management skills. - Strong written and oral communication skills. - Familiarity with the utilization review process preferred. - Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. - Broad knowledge of various insurances and government reimbursements is desirable. - Work independently, be self-directed and contribute as a member of a team. Physical Requirements The McLean Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. | |