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Utilization Review Specialist- Bluestone 


Job Summary: The Utilization Review Specialist will independently facilitate clinical reviews, as necessary, on admission and for continued stay care. The UM Specialist reviews the medical record to ensure medical necessity of admission as well as ongoing inpatient and outpatient treatment. The UR Specialist determines the avenues for advocacy on behalf of patients with managed care organizations for utilization of insurance benefits throughout the patient’s treatment. The UR Specialist will participate in multidisciplinary treatment team meetings in a meaningful collaborative effort to provide the highest quality of care for each patient.

Essential Duties and Responsibilities:

  • Completes initial, concurrent, and retrospective reviews of patient care in a timely manner to ensure continuous coverage for patients in inpatient treatment.
  • Initiates, schedules, and meaningfully participates in peer reviews and expedited appeals between third-party payers and facilities as needed.
  • Maintains sophisticated and current knowledge of mental health disorders including DSM-V knowledge, ICD-10 diagnoses and treatment processes.
  • Utilizes clinical information and knowledge of medical necessity criteria to effectively communicate plans of care and financial liability based on the needs of the member.
  • Collaborates with treatment team to discuss clinical authorization and quality of care.
  • Consistent and timely response to emails and other communications relating to utilization review.
  • Prepares and submits appeals utilizing their independent knowledge and expertise.
  • Maintains organized documentation in electronic health records and spreadsheet tracking system.
  • Ability to maximize reimbursement through effective utilization review.
  • Familiarity with processing correspondence with adherence to HIPAA guidelines.
  • Utilize verbal and physical de-escalation as warranted in order to keep patients safe and remain in warranted certification and training.

Other Duties and Responsibilities:

  • Adheres to all Hospital policies. Communicates effectively, both verbally and in writing.
  • Knowledge of using basic computer programs, including the Hospital’s electronic health record and other programs needed to complete the role.
  • Completes annual education requirements.
  • Attend scheduled staff meetings, supervision, and on-going training.
  • All required trainings, certifications and licensure must be kept current in accordance with applicable licensing and accreditation regulations and standards.
  • Respect the privacy of patients and hold in confidence all information obtained during the patient’s treatment. All patient-related documents should be handled in accordance with Agency guidelines on confidential material.
  • Maintain high standards of ethical and professional conduct and adhere to Agency policies and procedures.
  • Able to work independently and collegially with all clinical disciplines.
  • Knowledge of regulatory and reimbursement requirements.
  • Able to monitor and evaluate records for quality and appropriateness of care.
  • Other duties as assigned.

Education/Licensure Requirements:

  • Bachelor’s Degree in Nursing, Social Work, Mental Health/Behavioral Sciences, or related field required. Nursing degree preferred.
  • Valid Ohio License in Nursing, Social Work, Mental Health/Behavioral Sciences, or related field. Nursing license preferred.
  • Three to five (3-5) years Utilization Review experience.
  • Non-abusive Psychological and Physical Intervention (NAPPI) training required or able to get within one (1) month of hire date.
  • Experience working in utilization review in psychiatric field strongly preferred.
  • Experience in patient assessment, family motivation, treatment planning and communication with external review organizations or comparable entities.
  • Sensitivity in relating to persons of varying backgrounds and demonstrated ability to work with diverse groups of people possessing various strengths, aptitudes and abilities.
  • Ability to perform job responsibilities with a high degree of initiative and independent judgment.
  • Demonstrated oral and written communication skills and effective interpersonal skills.
  • Practical and creative problem solving skills.


Full-Time/Part-Time Full-Time  
Location Bluestone  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.  

This position is currently accepting applications.

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