Utilization Review Specialist (3-Month Contract) - Opportunity to Make a Difference

Overview:

Insight Global is looking for a Utilization Review Coordinator to evaluate the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the clients benefits plan. The LTSS Service Authorization Specialist is responsible for applying clinical and benefit administration policy guidelines to requests for authorizations for Long Term Services and Supports (LTSS). The LTSS Service Authorization Specialist provides accurate, prompt, and appropriate medical authorizations to requests from THE CLIENTS Clinicians, Vendors and Providers for LTSS. The LTSS Service Authorization Specialist reports to the LTSS Service Authorization Team Lead.

Day to Day:

- Conducts decision review for services requiring prior authorization in LTSS leveraging technology and guidelines as available.

- Applies clinical and benefit administration policy guidelines to requests for authorizations

- Communicates results of reviews in the centralized enrollee record for the primary care team and clinical reviewers.

- Works closely with Team Lead to facilitate escalated reviews in accordance to Standard Operating Procedures.

- Assures accurate documentation of clinical decision and works with Team Lead to ensure consistency in applying policy.

- Determines the need for additional structured clinical data for completion of service decision request.

- Handles all authorization requests timely and accurately, adhering to performance measures.

- Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements.

- Fulfills duties as above within service standard turnaround times.

Remote

Monday - Friday

9am-5pm EST