Utilization Reviewer

Our vision is a world of peaceful relationships with food, weight, and body image, where everyone with an eating disorder can experience recovery. We believe that exceptional, individualized care leads to lasting recovery from eating disorders. That’s why our teams are comprised of compassionate, dedicated professionals from a variety of backgrounds who collaborate to provide the very best evidence-based care for our clients at all levels of care.

The Utilization Reviewer (UR) is a strong advocate for clients to access medically necessary care by pursuing insurance authorizations for an individual’s recommended treatment. The UR is responsible for obtaining prior authorizations and concurrent review authorizations for intensive outpatient, partial hospitalization, residential, and inpatient eating disorder treatment. This position is critical for ensuring that clients can access the care they need for the recommended length of treatment. Schedule Monday-Friday, 8am-4:30pm Central Time Zone Remote

Review client medical records to gather clinical and medical information to provide to payers to support medical necessity for prior authorization requests for intensive (IOP and PHP), residential, and inpatient treatment Complete concurrent reviews by providing clinical and medical information to payers to support medical necessity for continued authorization of intensive (IOP and PHP), residential, and inpatient treatment, striving to obtain coverage for the recommended length of stay Provide discharge notification to insurance companies Schedule peer-to-peer reviews as requested between payers and clinical team members in accordance with team policies and procedures (e.g. scheduling waterfall) Communicate with insurance reviewers regarding clinical information requested and to resolve issues related to authorizations and coverage Collaborate with the clinical team to highlight any information that would strengthen the case for authorization, trigger the clinical team to add it to the client’s medical record, and present the additional, compelling information to the insurer Review insurance plan and benefits for admitting clients to ensure all pre-authorization requirements are known and met Develop and maintain strong and productive working relationships with review agencies Maintain up-to-date expertise and knowledge of insurance company authorization requirements, preferences, criteria, and strategies to support successful completion of authorizations Complete daily updates to the Census Web App to ensure the Admissions Coordinator Team has the necessary authorization information to support successful admissions to IOP, PHP, residential, and inpatient treatment Participate in the onboarding and orientation of new team members, including training and mentoring new URs and UR Assistants as assigned Provide back-up support to UR colleagues and UR Assistants during times of paid time off or vacancy Communicate and partner closely with UR Assistants to ensure all payer and admin tasks are completed timely Partner with the Medical Records and Revenue Cycle Management departments on authorization related appeals Coordinate with Specialty Access Services and Client Access on benefit related issues and single case agreements