Utilization Review Coordinator jobs in Toledo, OH

Description

Zepf Center has been serving the Lucas County community for nearly 50 years. We are the leading provider of behavioral health and substance use disorder services in Northwest Ohio. Services include adult and child psychiatric, substance abuse, case management, residential, Crisis Care, and therapy programs, as well as career development and wellness services. Zepf Center also offers primary care medical services to our patients to contribute to their continuum of care. Zepf Center is a trauma-informed agency and environment for both patients and staff.

We are currently seeking a full-time Utilization Review & Credentialing Specialist to serve as primary contact for all activities related to obtaining and tracking insurance prior authorizations and resolving denied service authorizations. Will perform provider enrollment and credentialing functions with various insurances and CAQH to ensure agency’s ability to receive timely reimbursement for services. Maintains working knowledge of all organizational authorization and enrollment requirements.

Essential Duties of this position include but are not limited to:

• Maintain a thorough, up to date understanding of service authorization requirements for all payers and state/ federal regulatory guidelines for coverage and authorization of treatment services.
• Coordinate with clinical team members to ensure required clinical documentation is obtained and provided to payers in order to procure necessary authorizations.
• Submit authorization requests to payers, perform tracking and follow-up as necessary to procure authorizations.
• Serve as a liaison between clinical, billing and payers to communicate authorization requirements and status.
• Monitor and analyze denial trends to develop appropriate processes to ensure successful authorization results.
• Monitor upcoming changes and trends for each payer to ensure appropriate procedures are put in place to avoid unnecessary disruptions in service delivery and payment.
• Monitor authorizations which are ending and request additional authorizations as needed.
• Utilize agency EHR to obtain and document data regarding prior authorization requests, approvals, and denials.
• Perform data entry tasks related to required patient data recordkeeping, including coverage plan updates.
• Assist with the credentialing, enrollment, dis-enrollment and revalidation processes for providers of medical and/or clinical services at agency.
• Work with agency providers to obtain personal information and credentialing documents required for agency billing.
• Assist with provider NPI applications and follow-up.
• Maintain current data for providers in agency and payer databases/online systems, including CAQH.
• Perform required monthly and quarterly checks via government databases such as OIG NPDB.
• Monitor license and certification expirations and work with agency providers to ensure timely renewal of same.
• Update agency and payer rosters to reflect new hires, terminations and provider changes in real time.
• Perform other duties as assigned.

Requirements

• Associate’s or Bachelors’ degree in a related field and 1 year experience or 3 years’ relevant experience including both behavioral health clinical or medical experience and administrative/ data entry experience.
• Broad understanding of behavioral health medical/ clinical terminology including both SUD and MH treatment.
• Basic understanding of behavioral health billing and prior authorization processes.