Career Opportunities at Acacia


Job Details

Behavioral Health

Utilization Review Specialist (CASAC)  Bronx, NY  : 12/31/2020
Job Description

Job ID#:


Job Category:

Behavioral Health

Position Type:

Full Time


The Utilization Review Specialist reports directly to the Program Director. The Duties & Responsibilities include • Coordinate, monitor and evaluate benefit services • Develop and maintain a directory of information for manage care providers. Keep case managers informed of any changes in benefits • Assist Case Managers in keeping accurate records meeting managed care requirements • Attend and participate in all required agency meetings: staff meetings, in-service training and weekly case review. The utilization review Specialist will work in Acacia Amanecer detox program site in the Bronx.
KEY ESSENTIAL FUNCTIONS:                                                                                                                          
  • Obtaining the required pre-authorization/certification of specified services from the MCO and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessary
  • Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident’s status to the MCO as scheduled
  • Acting as a liaison between the residential program and the MCO to better facilitate the reimbursement process
  • Referring MCO denials and non-covered medical services to the directors for appeal determination and next steps
  • Enter charges into Practice Management System
  • Knowledge of insurance products; CPT and ICD-10 coding
  • Third party insurance review of payments
  • Conduct medical record reviews of all managed care patients within the first 24 to 72 hours (if admitted on a Friday after 5:00pm) then weekly as required to promote desired clinical and financial outcomes by, but not limited to:
    • Meeting with all managed care residents/patients to better assist in the selection of appropriate provider resources and identification of quality and cost effective services throughout the continuum of care
    • Acting as a resource to the interdisciplinary team in regard to MCO requirements for admission, continued stay and discharge planning
    • Providing early identification of covered care and ensuring that claims are approved when the requirements are met
  • Collaborate with clinicians to identify discharge needs and coordinates with Social Services in the creation and implementation of a discharge/transfer plan
  • Must be familiarized with Managed Care providers to ensure proper processing of all required documents i.e. Appendix A,  LOCADTR
  • Maintain E-mail distribution daily
  • Ensure that documents are submitted to Managed Care providers within the required timeline,
  • Within 24-48hrs from point of admission
  • Ensure Discharge/Con-Current review documentation are completed within a timely manner. Complete follow-up call to ensure documents have been received/reviewed
  • Must confer with Medical Director when Doc to Doc review are being requested by manage care providers as well as CASAC managing the case
  • Track Re-Admissions trends to avoid denial by manage care providers
  • Communicate all appeal request to Unit Clerk to ensure charts are submitted to our finance dept. for processing within appropriate timeline 
  • Assist clients to resolve any problems and answer questions about their Manage Care benefits.
  • Educate eligible partner staff and prospective clients about benefits and how to access those benefits.
  • Ensure that all program outcomes are properly documented in an accurate and timely manner through program reporting systems
  • Work with leadership staff to use program performance data to drive improvements to the program design and implementation
  • Participate in all required trainings and meetings; maintain a strong and current expertise in public benefits eligibility, application, and enrollment, as well as community resources
  • Perform other duties as required
REQUIREMENTS: Experience and Special Requirements
High School diploma required; CASAC and/or bachelor’s degree in relevant field preferred. Relevant experience with special need population facing strong barriers towards benefits. Bilingual Spanish preferred. Excellent communication and computer skills. Comfortable working closely with others in a stressful environment. AGENCY PROFILE & EMPLOYEE
1)      Bilingual, Spanish and English
2)      Ability to work independently
3)      Familiarity with database and case noting
*Acacia Network is an equal opportunity employer*

Job Requirements


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