Utilization Management Specialist--Lawrence, Wichita, Pittsburg OR Pratt

Full-Time based in Lawrence, Wichita, Pittsburg or Pratt

 Position Overview:

  • Gathers necessary clinical information from facilities to obtain prior authorization and continuing authorizations from private insurance companies
  • Monitors authorization timelines within the ECR and works with clinical staff to ensure continued stay reviews are completed on time within established deadlines
  • Facilitates chart reviews weekly or at the time of the Continued Stay Review for active insurance funded clients to ensure payer standards and medical necessity criteria are met
  • Supports Therapists and other treatment staff to secure clinical information for insurance companies from admission through discharge
  • Facilitates retroactive quarterly chart reviews of private insurance clients to ensure standards are met and recommends continuous quality improvement strategies to address deficiencies
  • Ensures discharge planning and continuing care is documented according to insurance company guidelines
  • Understands and articulates to clinical staff medical necessity criteria for various insurance payers to ensure services are rendered and documented according to those criteria
  • Coordinates retroactive case reviews as requested by insurance companies
  • Coordinates clinical case appeals as necessary
  • Monitors compliance of new admission diagnoses are entered in the ECR by the required 72-hour time frame 

Requirements Include:

  • Requires high school diploma or equivalent; Bachelor's degree, Registered Nurse (RN) and/or Licensed Practical Nurse (LPN) preferred
  • Requires at least two years of related experience in mental health, substance use disorder treatment or in a medical setting
  • Requires a basic understanding of the treatment model utilized and a detailed understanding of substance use disorders, including assessment and medical necessity criteria
  • Experience and/or understanding of insurance terminology preferred
  • Requires some travel between DCCCA locations
  • Valid driver's license with a good driving record 
  • Must pass pre-employment background checks and drug screening
EOE