Utilization Review Manager - Home Care jobs in Orange, CA

JOB SUMMARY

The Utilization Review specialist is responsible for managing an active caseload of clients for the following levels of care: Detox, Residential, Intensive Outpatient, and Behavioral Health. S/he acts as a liaison between the Billing Manager, the client, and the Clinical Team. Candidate with at least three (3) years of clinical experience with addiction treatment of adults experiencing substance use problems and disorders. The review specialist is primarily responsible for ensuring that every client at our addiction treatment centers and primary mental health has the appropriate precertification and concurrent reviews completed in a timely manner.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The duties listed below are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to this class.

• Adhere to Alter Health Group's Policies and procedures.
• Assessing medical necessity for admission, reviewing appropriate levels of care.
• Perform initial evaluations of client needs and develop customized treatment plans.
• Complete precertification documentation upon client admission and retrospective reviews in a timely manner to ensure continuous coverage.
• Collaborate with clinicians in order to obtain necessary clinical documentation for reviews.
• Collaborate with admissions and management to determine appropriate length of stay and discharge dates.
• Reviewing all medical records before they are submitted.
• Updating spreadsheets for reporting and documentation purposes.
• ASAM (American Society of Addiction Medicine) charting standards.

ABILITIES

DEPENDABILITY:

Personally responsible; completes work in a timely, consistent manner; works hours necessary to complete assigned work; is regularly present and punctual; arrives prepared for work; is committed to doing the best job possible; keeps commitments.

ATTENDANCE AND PUNCTUALITY:

Is prompt and on time for works, assignments and meetings. Notifies supervisor prior to lateness or absence. Understands that excess absences pose a hardship on other employees.

JOB SKILLS AND KNOWLEDGE:

Employee completes all chart related documents and correspondence for assigned clients in a timely manner.

QUANTITY AND QUALITY OF WORK:

• Maintains high standards despite pressing deadlines; does work right the first time; corrects own errors; regularly produces accurate, thorough, professional work.
• Accepts responsibility for completing job tasks. Uses time productively and efficiently.

ATTITUDE:

• Demonstrates a cooperative, positive, and enthusiastic attitude toward fellow employees, clients, and visitors. Maintains a positive attitude in carrying out assignments and is helpful and courteous to fellow employees.
• Treats all people with respect; values diverse perspectives; participates in diversity training opportunities; provides a supportive work environment for a multicultural staff; shows sensitivity to individual differences; treats others fairly without regard to race, sex, color, religion, mental or physical ability, health status, nation of origin, gender identity or expression or sexual orientation; recognizes differences; takes advantage of opportunities to learn and gain by working together; values and encourages unique skills and talents; seeks and considers diverse perspectives and ideas.
• Works harmoniously with others to get a job done; responds positively to instructions and procedures; able to work well with staff, co-workers, peers and managers; shares critical information with everyone involved in a project; works effectively on projects that cross functional lines; helps to set a tone of cooperation within the work group and across groups; coordinates own work with others; seeks opinions; values working relationships; when appropriate facilitates discussion before decision-making process is complete.

CONFIDENTIALITY:

Always knows and follows applicable laws and regulations, and standard procedures.

COMMUNICATION SKILLS:

Is effective in written and oral expression. Demonstrates proper telephone etiquette and able to communicate easily with clients, referral sources, and visitors in an appropriate manner. Relates to clients and co-workers in a respectful and professional manner.

CONDUCT:

Conducts oneself in a manner consistent with the organization's Core Values and code of conduct. Shows professionalism in the office setting.

FLEXIBILITY / HANDLING EMERGENCIES:

Responds well to changing situations or routines. Handles crisis situations calmly and professionally.

COMPETENCIES:

To perform the job successfully, an individual should demonstrate the following competencies to perform the essential functions of this position.

• Analytical—the individual synthesizes complex or diverse information for each client LOC.
• Problem solving—the individual identifies and resolves authorization/ LOC problems in a timely manner and gathers and analyzes information skillfully.
• Oral communication—the individual speaks clearly and persuasively in LOC reviews in positive or negative situations, demonstrates group presentation skills and conducts productive meetings
• Delegation—the individual delegates work assignments, gives authority to work independently, sets expectations and monitors delegated activities.
• Leadership—the individual inspires and motivates others to perform well and accepts feedback from others.
• Quality management—the individual looks for ways to improve and promote quality and demonstrates accuracy and thoroughness within caseload.
• Judgment - the individual displays willingness to make decisions, exhibits sound and accurate judgment, and makes timely decisions.
• Planning/organizing—the individual prioritizes and plans caseload, work activities, uses time efficiently and develops realistic action plans.
• Safety and security—the individual observes safety and security procedures and uses equipment and materials properly.

MINIMUM QUALIFICATIONS:

EDUCATION/EXPERIENCE:

• Bachelors / Masters
• Undergrad in Psychology
• Minimum of 3 years experience in a related clinical setting. Managed Care and Utilization Management experience required.
• Behavioral Health Management experience with a concentration in substance abuse counseling required.

CERTIFICATES & LICENSES:

Has CPR and First Aid certifications.

KNOWLEDGE:

• An acute understanding of counseling and other treatment procedures for alcoholism and drug addiction related problems and primary mental health.
• A knowledge of regulations concerning alcoholism and drug addiction treatment and primary mental health.
• Working knowledge of alcoholism and drug addiction and treatment procedures for such illness.

Job Type: Full-time

Pay: $21.00 - $24.00

Work Remotely

• No

Job Type: Full-time

Pay: $24.00 - $28.00 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Application Question(s):

• Are you proficient in ASAM clinical charting criteria?
• Please provide your email address.
• This position is not remote and will be required to be in office at our company headquarters in Dana Point. Please confirm you understand this.

Education:

• Bachelor's (Preferred)

Experience:

• UR/Medical Billing for a behavioral healthcare: 2 years (Required)

Work Location: Multiple locations