Utilization Review Clinician

Description

Summary: Performs a clinical review and assesses care related to behavioral health and substance abuse, using utilization review criteria, technologies, and tools. 

Schedule: This position will range from 10-20 hours per week. It can be remote or onsite. It can be a contract 1099 position or part-time. There is a possibility for additional hours if you are interested in doing Assessments (ASAM certifiation would be required). 

Responsibilities: 

• Adhere to all Palmer goals, strategies, and values. 
• Maintain strict confidentiality in accordance with Palmer Polices and state and federal laws.
• Role model appropriate behavior, professional boundaries, respectful communication, and personal appearance in accordance with Employee Dress Code. 
• Conduct utilization management activities (i.e. initial and concurrent clinical reviews) assess, certify, and refer members for behavioral health services and conducts ongoing dialogue with providers related to appropriate managed care handling of the case needs.
• Communicate with clients, providers, and internal stakeholders to gather necessary information for utilization review decisions and ensure timely authorization of services.
• Monitor clients progress throughout the course of treatment, conducting ongoing reviews to assess effectiveness and make recommendations for adjustments as needed.
• Document all utilization review activities accurately and thoroughly, maintaining compliance with regulatory requirements and health insurance company policies.
• Conducts provider clinical chart audits and provider trainings as needed.
• Participate in interdisciplinary team meetings, case conferences, and quality improvement initiatives to enhance the delivery of behavioral health services and member outcomes.
• Stay informed about changes in healthcare regulations, clinical best practices, and industry trends to support informed decision-making and continuous improvement efforts.
• Uphold the highest standards of ethics, professionalism, and confidentiality in all interactions with members, providers, and colleagues.
• Collaborates closely with providers to gather necessary information and/or documentation required for reviews or appeals.
• Communicates with insurance companies to obtain status updates, resolve issues, and expedite approvals.
• Follows up on outstanding healthcare claims, ensuring accurate processing and payment.
• Assists in the appeals process by gathering required documentation, submitting appeals, and tracking outcomes.
• Monitors and manages pending utilization review requests, ensuring timely submission and follow-up.
• Check each document for accuracy, timeliness, and completeness in accordance with Palmer’s Policies and Procedures. 
• Maintain knowledge of agency policies, procedures and training. 
• Perform other duties as assigned by supervisor and/or Director.

This job description is not designed to contain a comprehensive list of activities, duties, and responsibilities that are required of the employee in this position. Responsibilities and requirements may change at any time with or without notice. 

Requirements

Requirements:

• Current Oklahoma LADC, LPC, LMFT or LCSW license 
• Master’s degree in behavioral science or related field
• At least 2 years of substance abuse experience
• Previous experience in Utilization Management or Managed Care, preferred
• Excellent verbal communication, written communication
• Advanced interpersonal skills
• Computer skills include Microsoft Word, Excel, and Outlook
• Minimum of 3 years’ experience in Insurance appeals & denials preferred
• Ability to effectively interact with different types of people.
• Strong organizational and time management skills.
• Precise attention to detail.

Physical Requirements:

• Ability to lift 30 pounds, sit for up to 8 hours/day, view computer screen for up to 8 hours/day.
• Job requires twisting, lifting, standing, sitting, walking, stretching, kneeling, bending, and squatting.

Palmer Continuum of Care, Inc. is a tobacco-free environment. Palmer does not allow the use of tobacco products in any program sites or vehicles by employees, consumers, volunteers or visitors. Employees shall not use to tobacco products while providing services in a consumer’s or consumer’s extended family’s home.