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Utilization Review Manager

Job Details

Job Location

East Hampton Residential - Wainscott, NY

Position Type

Full Time

Education Level

Graduate Degree

Salary Range

$80000.00 - $90000.00 Salary/year

Travel Percentage

Up to 25%

Job Shift

Morning

Job Category

Nonprofit - Social Services

Description

SUMMARY

The Utilization Review (UR) Manager coordinates commercial, and Medicaid Managed Care benefits and approvals for patients receiving behavioral health services. The Manager will monitor claims and approvals to ensure uninterrupted service provision. This position is responsible for all verbal and written documentation as required by payors. The manager will supervise the Utilization Review Department for the OASAS residential programs.

**ESSENTIAL DUTIES AND RESPONSIBILITIES** include the following. Other duties and responsibilities may be assigned.

• Complete VOB’s (Verification of Benefits) / insurance eligibility

• Obtain initial and concurrent authorizations

• Complete peer reviews as needed

• Communicate discharge information to insurance companies

• Initiate and resolve appeals

• Work with the clinical and nursing teams to obtain up to date information needed for reviews

• Participate in weekly clinical case conferences

• Utilize OASAS LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 criteria to identify and advocate for appropriate level of care placement

• Develop and maintain effective relationships with stakeholders including current and prospective referral sources, insurers/pay sources, Phoenix House clinical and medical staff and management

• Advocate on behalf of Phoenix House and its patients with insurers/pay sources and others regarding treatment protocols, medical necessity issues, and quality of care matters

• Train staff on insurance utilization review and authorization procedures, and other managed care concerns to ensure prompt and effective information-sharing and service documentation

• Responsible for consistent and timely reporting on key business metrics

• Supervise and support the UR team managing all OASAS Residential Authorizations

COMPETENCIES (KSAs)

• Ethical Practices

• Judgment

• Relationship Management

• Emotional Intelligence

• Empathy

• Professional Boundaries

• Interview Skills

• Global and Cultural Awareness

• Critical Evaluation

• Problem Solving

• Decision Making

• Communication

• Teamwork

• Crisis Management

• Technical Capacity

Qualifications

REQUIRED EDUCATION

• Master’s degree in social work, Mental Health Counseling or related field

LICENSE/CERTIFICATIONS

• NYS LMSW, LMHC in good standing required

REQUIRED EXPERIENCE

• Minimum two years of experience working with Managed Behavioral Health Organizations (MBHOs), billing and claims management

WORK ENVIRONMENT

• This role routinely uses standard office equipment such as computers, phones and copy machines.

• This job has an opportunity to be hybrid, working some days remote and some days in office.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties and responsibilities of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.

• Regularly required to sit, use hands to type, handle or feel objects, tools or controls; reach with hands and arms, and talk or hear.

• Frequently required to stand, walk, stoop, kneel or crouch.

Phoenix House is an Equal Opportunity Employer providing equality of opportunity to all who are protected against discrimination by law, regulation or executive order, including veterans and individuals with disabilities. EEO is the Law: Applicants and employees are protected under Federal law from discrimination. Click https://www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf to learn more.