utilization review specialist

Emory Healthcare

<div>Overview:
<div>
Be inspired. Be rewarded. Belong. At Emory Healthcare.</div><div></div><div> 
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:</div><ul><li>
Comprehensive health benefits that start day 1</li><li>
Student Loan Repayment Assistance &amp; Reimbursement Programs</li><li>
Family-focused benefits
</li><li>Wellness incentives</li><li>
Ongoing mentorship, development, leadership programs and... more!</li></ul>
Description:
<div>
Job Summary: The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. Primary duties and responsibilities: Operational Support: 1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 2. Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department&Acirc;&iquest;s processes. 4. Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data. 5. When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay. 6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 7. Follow the UR Department&Acirc;&iquest;s denial workflows as appropriate. 8. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. Compliance: 1. Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan. 3. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements. Collaboration: 1. Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or continued stay on individual patient basis based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided. 3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team. 4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments. Additional Responsibilities: 1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned. Travel: Less than 10% of the time may be required. Work Type: This position is a remote position outside traditional office, often from home or another remote setting.
 
 
Minimum Qualifications: Education - Associate degree in nursing. Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience. Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board. Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies. Preferred Qualifications: Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred. Skills - InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred.
 
 
PHYSICAL REQUIREMENTS: Occasional to frequent sitting. Close eye work (computers, typing, reading, writing).
 
 
ENVIRONMENTAL FACTORS: Remote position.</div>
Additional Details:
<div>
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.</div><div></div><div> 
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare&rsquo;s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.</div></div>

Utilization Review Specialist

Ensemble Health Partners

<div>Thank you for considering a career at Ensemble!
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.
Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!
O.N.E Purpose:<ul><li>
Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.</li><li>
Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.</li><li>
Striving for Excellence: Execute at a high level by demonstrating our &ldquo;Best in KLAS&rdquo; Ensemble Difference Principles and consistently delivering outstanding results.</li></ul>
The Opportunity:
<div><div>Job Description</div></div><div>
CAREER OPPORTUNITY OFFERING:<ul><li>
Bonus Incentives</li><li>
Paid Certifications</li><li>
Tuition Reimbursement</li><li>
Comprehensive Benefits</li><li>
Career Advancement</li></ul>
This position pays between:<ul><li>
RN pay scale $32.65 - $35.85/hr based on experience</li><li>
LPN pay scale $24.65 - $26.35/hr based on experience</li><li>
$$ Shift Differential for Select Shifts $$</li></ul>
**Must have Current unrestricted LPN or RN license (required) or RN compact license (preferred)**
We are seeking Virtual Utilization Review Specialists who are interested in compressed, weekend work schedules. The schedules we are offering include:
Work Schedule:
Full-time:<ul><li>
Friday, Saturday, Sunday: 7:00 AM - 7:00 PM with a 4 hour shift on Wednesday</li></ul>
Resource Utilization<ul><li>
Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services</li><li>
Initiates appropriate referral to physician advisor in a timely manner</li><li>
Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team</li><li>
Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers</li></ul>
Medical Necessity Determination<ul><li>
Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews, possibly from an offsite location</li><li>
Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission</li><li>
Communicates all medical necessity review outcomes to in-house care management staff and relevant parties as needed</li><li>
Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care</li><li>
Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers</li></ul>
Denial Management<ul><li>
Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process</li><li>
Maintains appropriate information on file to minimize denial rate</li><li>
Assist in recording denial updates; overturned days and monitor and report denial trends that are noted</li><li>
Monitor for readmissions</li></ul>
Quality/Revenue Integrity<ul><li>
Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators</li><li>
Accurately records data for statistical entry and submits information within required time frame</li><li>
Responsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflow</li><li>
Accurately records data for statistical entry and submits information within required time frame</li><li>
Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management</li><li>
Second-level physician reviews will be sent as required and responses/actions reflected in documentation</li></ul>
Facilitation of Patient Care<ul><li>
Prioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria</li><li>
Collaborates with the in-house care manager Maintains rapport and communication with the in-house care manager Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment</li><li>
Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures</li></ul>
Communication<ul><li>
Directs physician and patient communication regarding non-coverage of benefits</li><li>
Maintains positive, open communication with the physicians, nurses, multidisciplinary team members and administration</li><li>
Educates hospital and medical staff regarding utilization review program</li><li>
Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis</li><li>
Voicemail, Skype, and email will be utilized and answered in timely fashion</li><li>
Hospital provided communication devices will be used during work hours</li><li>
Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements</li><li>
Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made</li></ul>
Team Affirmation<ul><li>
Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in and offers to help</li><li>
Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities</li><li>
Provides back-up support to other departmental staff as needed</li></ul>
Other Job Functions<ul><li>
Complies with FCC and department policies and procedure, including confidentiality and patient&rsquo;s rights</li><li>
Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities (i.e., medical necessity criteria, MS-DRGs, POA)</li><li>
Actively participates in departmental meetings and activities</li><li>
Participates in FCC and community committees as assigned</li><li>
Actively participates in conferences, committees, and task forces as directed by the FCC division</li><li>
Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation</li></ul>
Experience:<ul><li>
Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field</li><li>
Current unrestricted LPN or RN license required; RN compact license preferred</li><li>
Five years nursing experience in an acute care environment preferred</li><li>
Utilization review/discharge planning experience preferred</li><li>
Recent experience or working knowledge of medical necessity review criteria preferred</li><li>
Current working knowledge of quality improvement processes</li><li>
Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.</li><li>
This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.</li></ul>
Other Knowledge, Skills, and Abilities Required:<ul><li>
Ability to work a compressed weekend schedule</li><li>
This is a remote role which requires access to high speed internet</li><li>
Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues</li><li>
Commitment to exceptional customer service at all times</li><li>
Communicate ideas and thoughts effectively verbally and in writing</li><li>
Strong clinical assessment, organization and problem-solving skills</li><li>
Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes</li><li>
Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment</li><li>
Resourceful and able to work independently</li></ul>
#LI-LS1
#LI-REMOTE</div>
Join an award-winning company
Five-time winner of &ldquo;Best in KLAS&rdquo; 2020-2022, 2024-2025
Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024
22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024
Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024
Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023
Energage Top Workplaces USA 2022-2024
Fortune Media Best Workplaces in Healthcare 2024
Monster Top Workplace for Remote Work 2024
Great Place to Work certified 2023-2024<ul><li>
Innovation</li><li>
Work-Life Flexibility</li><li>
Leadership</li><li>
Purpose + Values</li></ul>
Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:<ul><li>
Associate Benefits &ndash; We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.</li><li>
Our Culture &ndash; Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
</li><li>Growth &ndash; We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.</li><li>
Recognition &ndash; We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.</li></ul>
Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.
Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com.
This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role&rsquo;s range.
Employment Disclaimers &ndash; Ensemble</div>

Virtual Utilization Review Specialist - WEEKENDS

PrairieCare

<div>About Us:
<div>
Join PrairieCare: Transform Lives Through Meaningful Work!</div><div></div><div> 
Are you ready to embark on a rewarding career in psychiatric healthcare? At PrairieCare, we are passionate about delivering exceptional mental health services to individuals in need. Our comprehensive approach covers the entire spectrum of care, creating a wealth of diverse roles for those who aspire to make a real impact.</div><div>
We believe in nurturing talent and fostering professional growth in a supportive environment. Here, you won&rsquo;t just find a job&mdash;you&rsquo;ll discover a fulfilling career path in the mental health field.</div><div>
If you're eager to contribute to a mission-driven organization and help change lives for the better, we invite you to join our dedicated team at PrairieCare. Together, we can make a profound difference in the lives of those we serve!</div>
Responsibilities:
<div>
 Join Our Dynamic Team as a Utilization Review Specialist</div><div></div><div> 
Are you passionate about making a difference in the lives of those with psychiatric illnesses? Do you thrive in a collaborative environment where your expertise can shine? If so, we have the perfect opportunity for you!</div><div></div><div> 
What You'll Do: As our Behavioral Health Liaison, you will be the vital link between our dedicated clinical treatment team and third-party payers, ensuring that every patient receives the appropriate treatment they deserve. Your role will include:</div><div>
✅ Securing Authorizations: Obtain initial behavioral health authorizations and conduct thorough concurrent reviews to keep our patients on the path to recovery.</div><div>
✅ Collaborative Decision-Making: Work closely with the clinical treatment team to assess the need for denial of stay when patients no longer meet acute care criteria, facilitating timely and appropriate actions.</div><div>
✅ Stay Informed: Maintain an up-to-date understanding of contract requirements for all third-party payor groups, ensuring compliance and optimal patient care.</div><div>
✅ Track Progress: Monitor each patient&rsquo;s treatment journey through inpatient, partial hospitalization, and Intensive Outpatient Programs (IOP), ensuring they receive the best possible support.</div><div>
✅ Cultural Competence: Bring your knowledge of gender, cultural differences, and age-appropriate care to the forefront of Utilization Review, enhancing our approach to diverse patient needs.</div><div>
Why Join Us? At our organization, you&rsquo;ll be part of a passionate team committed to improving mental health care. We value your expertise and provide ongoing training and support to help you excel in your role.</div><div>
 Make a Difference Today! If you&rsquo;re ready to take on a rewarding challenge and be a champion for those in need, apply now and help us transform lives through compassionate care!</div><div></div><div> 
We are excited to hear about your interest in this opportunity! If you have any questions or need assistance with the application process, please feel free to contact me directly at Sydney Spencer, either via email at sydney.spencer@newporthealthcare.com or by phone at 615-961-4138. If you need further support, you are also welcome to reach out to our careers and management team at careers@newporthealthcare.com.
</div>Qualifications:
<div>
What You'll Bring:</div><div></div><ul><li> 
At least two (2) years of work experience in the behavioral health field.
</li><li>Active license or credential in a behavioral health field preferred.
</li><li>Bachelor&rsquo;s or Master&rsquo;s in a behavioral health related specialty preferred.</li></ul><div> 
Benefit options include:</div><ul><li>
Medical/Dental/Vision</li><li>
Company paid life insurance</li><li>
Paid time off including sick time</li><li>
Voluntary Short term and long-term disability</li><li>
401K with company match</li><li>
Flexible spending accounts</li><li>
Tuition Reimbursement</li><li>
Student Loan Repayment</li><li>
Free parking</li><li>
Free 24/7 Fitness Center</li></ul><div>
Join Us:</div><div>
Join us in our mission to provide outstanding support and make a meaningful difference in the lives of those we assist. Your contributions can help shape the future of our care services&mdash;apply today!</div><div></div> 
PrairieCare Healthcare is an Equal Opportunity Employer.
PrairieCare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, genetic information, or any other characteristic protected by federal, state, or local laws.
PrairieCare is committed to ensuring equal employment opportunity, including providing reasonable accommodations to individuals with disabilities. Applicants with a physical or mental disability who require a reasonable accommodation for any part of the application or hiring process are encouraged to email careers@newporthealthcare.com for assistance.<div> 
#LI-SS1</div></div>

Utilization Review Specialist (or UR Nurse)

JOL Healthcare

<div>The Utilization Review Nurse (RN) is responsible for evaluating the medical necessity, appropriateness, and efficient use of hospice services through detailed clinical chart review, utilization monitoring, and workflow oversight. This role ensures that hospice care delivery aligns with Medicare Hospice Conditions of Participation (42 CFR Part 418), Texas regulations, and agency policy. The Utilization Review Nurse places strong emphasis on accurate, timely, and compliant documentation within the Homecare Homebase (HCHB) EMR system and collaborates closely with interdisciplinary team (IDG) members to support high-quality, compliant hospice care.
Essential Functions:
Utilization Review &amp; Clinical Oversight:
<ul><li>Conduct a comprehensive review of hospice admission documentation, ongoing clinical assessments, visit notes, plans of care (POCs), physician orders, certifications of terminal illness (CTIs), and related records to confirm hospice eligibility, medical necessity, and regulatory compliance.
</li><li>Ensure documentation supports terminal illness prognosis, hospice eligibility criteria, and continued appropriateness of services in accordance with Medicare hospice regulations.
</li><li>Review interdisciplinary group (IDG) documentation to ensure plans of care reflect patient needs, goals, and hospice levels of care.
</li><li>Collaborate with clinical staff to clarify, educate, and correct documentation discrepancies on time.
</li><li>Evaluate visit utilization patterns, levels of care, and service frequency to promote efficient care delivery while supporting compliance and reimbursement integrity.
</li><li>Participate in the assigned Administrator-on-Duty (AOD) on-call rotation, providing administrative and clinical support after hours under the direction of the Hospice Administrator and Director of Nursing. This role does not serve as the licensed Hospice Administrator.
</li></ul>HCHB Workflow Monitoring:
<ul><li>Monitor and manage clinical workflow within the HCHB system to ensure timely completion of documentation, orders, and visit notes.
</li><li>Track pending tasks, outstanding physician orders, certifications, and incomplete documentation using HCHB dashboards and reports.
</li><li>Identify workflow delays or compliance risks and proactively communicate with appropriate team members to facilitate resolution.
</li></ul>Quality &amp; Compliance Support:
<ul><li>Participate in internal audits and mock surveys to support readiness for CMS, Texas Health and Human Services, and accrediting organization reviews.
</li><li>Assist with performance improvement initiatives related to hospice utilization, documentation accuracy, and quality outcomes.
</li><li>Support compliance with federal and state hospice regulations, payer requirements, and agency policies and procedures.
</li></ul>Staff Support &amp; Education:
<ul><li>Provide ongoing feedback and education to clinicians related to hospice documentation standards, utilization expectations, and regulatory requirements.
</li><li>Assist with onboarding and training of new clinical staff related to HCHB workflows, hospice documentation protocols, and utilization review processes.
</li></ul>Education:
Graduate of an accredited School of Nursing; BSN preferred.
License/Certification:
<ul><li>Current RN license in the state of Texas.
</li><li>Current BLS certification.
</li></ul>Experience:
<ul><li>Minimum 2 years of clinical hospice experience.
</li><li>Strong knowledge of Medicare hospice Conditions of Participation (42 CFR Part 418), hospice eligibility criteria, and interdisciplinary team processes.
</li><li>Experience with Homecare Homebase (HCHB) is strongly preferred.
</li></ul>Skills:
<ul><li>Proficient with electronic medical record systems and Microsoft Office applications.
 
Strong organizational, analytical, and communication skills.
</li><li>Ability to manage multiple priorities while meeting regulatory and operational deadlines.
</li><li>Working knowledge of Medicare and Medicaid hospice regulations.
</li></ul>Environmental and Working Conditions:
<ul><li>Primarily office-based with potential for remote/hybrid work (based on agency policy).
</li><li>May require minimal travel for field support or in-person training.
</li><li>Frequent use of computer systems and prolonged screen time.
</li></ul>Physical and Mental Effort:
<ul><li>Prolonged sitting and computer use are required.
</li><li>Ability to manage stressful situations calmly and courteously.
</li><li>Requires working under some stressful conditions to meet deadlines and patient needs.</li></ul></div>

Hospice Utilization Review Nurse

TEEMA

<div>Job Summary
Prior Authorization
TeemaGroup
Full-time
In-Office | White Plains, NY, United States 
Overview: 
The Prior Authorization &amp; Billing Specialist plays a critical role in ensuring timely access to mental health services by managing insurance authorizations, billing processes, and reimbursement workflows. This position serves as a key liaison between clinical teams, insurance payers, and patients, ensuring services are authorized, accurately billed, and compliant with regulatory and payer requirements. This role is ideal for a detail-oriented professional passionate about supporting behavioral health access through strong administrative and revenue cycle expertise. 
 
What you will be doing: 
Prior Authorization &amp; Utilization Management<ul><li>
Obtain and manage prior authorizations for outpatient and inpatient mental health services, including therapy, psychiatry, psychological testing, and intensive programs.</li><li>
Review clinical documentation to ensure medical necessity and payer compliance.</li><li>
Submit authorization requests to insurance companies via portals, phone, or electronic systems.</li><li>
Track authorization approvals, denials, expirations, and extensions; proactively follow up to prevent treatment delays.</li><li>
Communicate authorization status clearly with clinicians, scheduling staff, and leadership.</li><li>
Assist with peer-to-peer reviews and appeals when authorization is denied or partially approved.</li></ul>
Billing &amp; Revenue Cycle Support<ul><li>
Submit accurate and timely claims for mental health services to commercial, Medicaid, and Medicare payers.</li><li>
Verify insurance eligibility, benefits, and coverage limitations prior to services.</li><li>
Review Explanation of Benefits (EOBs) and remittance advice for accuracy.</li><li>
Identify, research, and resolve claim denials, underpayments, and rejections.</li><li>
Post payments and adjustments accurately when applicable.</li><li>
Maintain compliance with CPT, ICD-10, and modifier guidelines specific to behavioral health billing.</li></ul>
Administrative &amp; Compliance Responsibilities<ul><li>
Maintain accurate patient authorization and billing records within electronic health record (EHR) and billing systems.</li><li>
Ensure compliance with HIPAA, payer contracts, and internal policies.</li><li>
Collaborate with clinical, administrative, and finance teams to optimize workflows and reduce revenue leakage.</li><li>
Monitor payer requirements, policy changes, and authorization rules related to mental health services.</li><li>
Prepare reports related to authorization turnaround times, denial trends, and billing performance.</li><li>
Perform other related duties as assigned.</li></ul> 
What you must have: 
Education and Experience<ul><li>
High school diploma or equivalent required; associate or bachelor&rsquo;s degree in healthcare administration or related field preferred.</li><li>
Minimum of 2 years of experience in prior authorization, utilization review, medical billing, or revenue cycle operations.</li><li>
Experience in mental health or behavioral health services strongly preferred.</li></ul>
Knowledge, Skills, and Abilities<ul><li>
Strong understanding of prior authorization processes and insurance requirements.</li><li>
Knowledge of behavioral health billing practices, CPT and ICD-10 coding, and payer guidelines.</li><li>
Excellent attention to detail and organizational skills.</li><li>
Ability to manage multiple priorities in a fast-paced environment.</li><li>
Strong written and verbal communication skills, including professional interaction with payers and clinical staff.</li><li>
Ability to work independently while collaborating effectively with a team.</li><li>
Proficiency with EHR systems, billing software, and Microsoft Office applications.</li></ul> 

#Workwolf</div>

Billing Specialist

NeuroPsychiatric Hospitals

<div>About Us:
<h3 class="jobSectionHeader">Healing Body and Mind.</h3><div>
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. Our hospitals use an interdisciplinary, multi-specialty approach that delivers high-quality, patient-centered care when it&rsquo;s needed most.</div><div>
With locations in Indiana, Michigan, Texas, and Arizona, we&rsquo;re expanding access to our unique model of care across the United States. Join us and be part of a team dedicated to making a lasting difference in the lives of patients and families every day</div>
Overview:
<div>
Medical Behavioral Hospital of Clear Lake is looking for a Utilization Review Coordinator to coordinate patients&rsquo; services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary teams.</div><div></div><div> 
Benefits of joining NPH</div><ul><li>
Competitive pay rates</li><li>
Medical, Dental, and Vision Insurance</li><li>
NPH 401(k) plan with up to 4% Company match</li><li>
Employee Assistance Program (EAP) Programs</li><li>
Generous PTO and Time Off Policy</li><li>
Special tuition offers through Capella University</li><li>
Work/life balance with great professional growth opportunities</li><li>
Employee Discounts through LifeMart</li></ul>
Responsibilities:
<ul><li>Filing documents as needed.</li><li>
Initial Precertification with payors.</li><li>
Concurrent Clinical review with payors.</li><li>
Document in the electronic system daily in real time.</li><li>
Admission audit.</li><li>
Ensures that CON&rsquo;s/RON&rsquo;s and CMS certifications are completed by provider.
</li><li>Consistently demonstrates professionalism with all internal and external customers as evidenced by positive customer and peer Communicates effectively with all staff and patients as evidenced by the establishment and maintenance of productive working relationships.</li><li>
Maintains knowledge of current trends and developments in the field by reading appropriate books; journals and other literature and attending related seminars or conferences.</li><li>
Maintains a professional approach with Assures protection and privacy of health information as attained through written, electronic or oral disclosures.</li><li>
Cooperates and maintains good rapport with nursing staff, medical staff, and other departments.</li><li>
Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital polices that apply.</li><li>
Complies with hospital expectations regarding ethical behavior and standards of conduct.</li><li>
Complies with federal and hospital requirements in the areas of protected health information and patient information.</li><li>
Reconsiderations, assists with appeals as needed, arrange peer to peer level reviews, and report the outcomes to the VP of Care Management and Team.</li><li>
Provides education to nursing staff. ;eadership team, and providers regarding documentation.</li><li>
Actively works with the business office regarding resolution of appeals/denials and retrospective reviews.</li></ul>
Qualifications:

Education: Bachelor's in Behavioral Health, Social Work, Counseling, Nursing or Psychology required. Master's degree preferred.
Experience: Minimum of 2 years of utilization review experience in a hospital setting required. Minimum of 2 years of case management experience, including discharge planning in a hospital setting required.<div>
Licensure: Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred. Basic Life Support (BLS) and Handle with Care (HWC) obtained during orientation, if applicable.</div><div>
Skills: Must have strong knowledge of medications and demonstrate exceptional time management, data entry, and communication skills. Must be detail oriented.#INDEEDLOW</div></div>

Utilization Review Coordinator

NMC Health plc

<div>The Case Manager is responsible for coordinating patient care, managing insurance approvals, monitoring resource utilization, and ensuring efficient discharge planning while supporting the Revenue Cycle Department. The role focuses on optimizing insurance approvals, reducing claim denials, ensuring medical necessity documentation, and improving hospital revenue through effective case and utilization management in compliance with UAE healthcare regulations.</div>
 <div><div><ul><li>Case Management &amp; Care Coordination
</li></ul></div><ul><li>Assess patient medical and clinical needs
</li><li>Coordinate with physicians and nursing teams for treatment planning
</li><li>Monitor patient progress and length of stay
</li><li>Identify high-risk and long-stay patients
</li><li>Facilitate patient transfers in collaboration with clinical teams, ensuring medical records, treatment plans, and discharge documentation are complete. 
</li></ul>2. Insurance &amp; Revenue Cycle Coordination
<ul><li>Coordinate with insurance companies and TPAs for approvals through the RCM Approval unit
</li><li>Ensure timely pre-authorizations and concurrent approvals
</li><li>Monitor insurance coverage and eligibility
</li><li>Support denial prevention and claim accuracy
</li><li>Work closely with billing and coding teams
</li><li>Ensure proper clinical documentation for claims submission
</li><li>Facilitate insurance company and TPA visits for medical file reviews and case audits.
</li><li>Monitor and ensure timely bill updates by coordinating with clinical, coding, and billing teams to avoid claim delays and ensure accurate revenue capture. 
</li></ul><div><ul><li>Real-Time Visibility &amp; Escalation of Inpatient Pending Approvals
</li></ul></div>Maintaining real time tracking of all Inpatient pending approvals and escalate cases exceeding defined turnaround times to relevant stakeholders (Clinical team, RCM insurance). 
<ul><li>
</li></ul>4. Utilization Management
<ul><li>Monitor Average Length of Stay (ALOS)
</li><li>Ensure efficient use of hospital resources
</li><li>Conduct concurrent and retrospective case reviews
</li><li>Support cost-effective treatment planning
</li>Ensure compliance with payer guidelines 
<li>
</li></ul>5. Discharge Planning
<ul><li>Coordinate safe and timely discharge
</li><li>Ensure discharge documentation is complete
</li>Coordinate follow-up care and insurance approvals 
<li>
</li></ul>6. Documentation &amp; Compliance
<ul><li>Coordinate with the clinical team to ensure proper and complete medical documentation to support insurance approvals, coding, and billing requirements.
</li><li>Maintain accurate case management records
</li><li>Ensure compliance with health regulations, Insurance policies, and hospital revenue cycle policies
</li><li>Support Insurance audits
</li><li>Prepare utilization and case management reports 
</li></ul>7. Revenue &amp; Quality Support
<ul><li>Reduce insurance rejection rate
</li><li>Improve approval turnaround time
</li><li>Support revenue optimization
</li><li>Monitor case management KPIs
<ul><li>Insurance Inpatient approval turnaround time
<ul><li>Reduce Rejection Rate
</li><li>Average Length of Stay (ALOS)
</li><li>Claim documentation accuracy
</li><li>Discharge efficiency
</li><li>Revenue cycle support performance
</li><li>Utilization review compliance
</li><li>Patient throughput
</li></ul></li></ul></li><li>Participate in revenue cycle and clinical meetings</li></ul></div>
 <div>Education
<div><ul><li>MBBS / MD / BSN
</li></ul><ul><li>Certified Professional Coder
</li></ul></div>Experience
<ul><li>Minimum 3 years UAE Hospital experience
</li><li>Experience in case management, utilization review, discharge planning preferred
</li></ul>Experience working with insurance and TPAs is an advantage</div>

Case Manager

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