Utilization Review Specialist

General Summary of Duties: The Utilization Review Specialist uses their clinical experience to conduct utilization reviews to determine medical necessity and resource consumption during any course of treatment that occurs at the Agency, both inpatient and outpatient. The Utilization Review Specialist also engages in internal auditing of clinical records to ensure charts meet statute and MCO reporting requirements.

The Utilization Review Specialist assists in the operations of Kitsap Mental Health Services (KMHS) in support of its stated mission and provides the highest level of customer service to internal departments and clients served by the Agency.

Major Responsibilities/Tasks:
  • Analyze and Review clinician requests for reauthorization of the level of care to determine whether the client is meeting: (a) Medical Necessity and (b) Agency Level of Care Standards.
  • Consult with appropriate leadership for Level of Care denials to ensure that standards are met.
  • Manage the reporting and data gathering processes in order to maintain statistical information related to medical necessity, resource utilization, and compliance with WAC and MCO reporting requirements.
  • Facilitate further clinical review of charts for WAC compliance and Level of Care assessments upon recommendation from the Utilization Review Coordinator.
  • Acts as liaison for all-payer audits, specifically the Managed Health Care Organizations.
  • Coordinates between internal departments to gather required information for audit requests.
  • Manages all Managed Health Care outcomes (i.e. corrective action, additional documentation needed, etc.).
  • Reviews and updates the audit tools based on payer audits to ensure compliance.
  • Complete all required documentation and data entry of clients outcomes and program performance as outlined in the appropriate KMHS guidelines, manuals, policies, and procedures.
  • Attend all mandatory meetings and trainings on time and as scheduled.
  • In addition to the above, any other responsibilities assigned by the supervisor that are appropriate to the position and not specifically listed in the job description.

KMHS is an equal opportunity employer that does not discriminate against people regardless of age, genetic information, national origin, race/color, ethnicity, gender identity, sexual orientation, neurodiversity, disability, or veteran status. KMHS envisions an anti-racist, equitable, inclusive, and collaborative community in which all can feel welcome.

Benefits:
  • Comprehensive and generous health, dental and vision benefits
  • Up to 19 days of PTO and 8 paid holidays your first year (pro-rated for part-time)
  • An incredible team approach that is dynamic and collaborative
  • Loan Forgiveness, training, and extensive education available
  • Multiple locations and opportunities close to home
  • Advancement opportunities available within the agency
  • Free Employee Assistance Program and parking
  • Full Time, Part Time and PRN positions along with flexible hours for professional advancement


Qualifications

Minimum Qualifications:

EDUCATION: Bachelors Degree in nursing, social work or behavioral health field.

EXPERIENCE: Experienced (minimum 2 years of job-related experience)

Minimum of 2 years of direct clinical experience in psychiatric or mental health treatment.

Possess and maintain a valid driver's license with an acceptable motor vehicle report.

Preferred Qualifications:

EDUCATION: Masters Degree in nursing, social work, or behavioral health field.

EXPERIENCE: Experienced (minimum 4 years of job-related experience)

Experience in patient assessment, family motivation, treatment planning and communication with external review organizations or comparable entities.