Job Description

Medusind is a leading provider of revenue cycle management solutions to dental, behavioral health, anesthesia, pathology, emergency, surgery, radiology, and other specialties. In January 2023, Alpine Investors, a people-driven private equity firm, invested in Medusind to continue to advance its leadership position as one of the top revenue cycle management companies in the country.

Position Overview:

The UR Representative is responsible for conducting Utilization Reviews (UR) to ensure appropriate authorization for behavioral health services. This role involves reviewing cases via multiple platforms, coordinating peer reviews, entering authorization data, following up on approvals, and maintaining clear communication with facilities. Strong knowledge of levels of care, prior authorization processes, and behavioral health policies is required.

Key Responsibilities:

Utilization Review & Authorization Management:

• Lead training for new onshore Reps and oversee the development of payer-specific training materials.
• Conduct CDI and documentation standardization training across customers to improve quality and compliance.
• Partner with QA to perform ongoing UR audits and monitor accuracy trends.
• Support knowledge transfer to Cognizant Training Leads and ensure timely dissemination of new payer/process updates.
• Conduct Admin, Concurrent Utilization, and Retro Reviews via: Live, Voicemail, Fax, and Portal Reviews. 
• Coordinate Peer Reviews as needed.
• Provide the Assignment of Responsibility (AOR) form templates at admission if required by the facility.
• Enter UR authorization information into the facility's EMR billing system and internal workflow systems.
• Ensure follow-ups on pending authorizations to secure required approvals and documentation.

Documentation & Tracking:

• Accurately document and track all UR activities in Salesforce and other designated systems.
• Assist with document retrieval from EMRs when necessary.

Communication & Coordination:

• Serve as a liaison between the facility and internal teams.
• Send morning and end-of-day emails to facilities with status updates.
• Provide weekly email summaries to keep stakeholders informed.

Expertise & Compliance:

• Maintain a strong understanding of levels of care, insurance authorization requirements, and behavioral health regulations.
• Identify and address gaps in documentation that could impact authorization approvals.
• Ensure all UR requests for Authorization comply with relevant policies and payer requirements, and assist in providing information/training to the facility to ensure the above.
• Additional Duties as Assigned: Assist with other tasks that align with UR and prior authorization responsibilities as needed.

Requirements:

Educational Background :

• Bachelor’s degree in Data Analytics, Business, Finance, Healthcare Administration, or related field (preferred).

  Experience :

• Experience in Utilization Review, Behavioral Health, or Prior Authorization.

Expert Industry Knowledge : 

• Knowledge of insurance authorization processes, levels of care, and medical necessity criteria.

Collaboration & Communication : 

• Excellent verbal and written communication for facility interactions.

Detail-Oriented : 

• High level of accuracy, Strong organizational, follow-up, and documentation skills.

Technical skills:

• Proficiency in EMR systems, Salesforce, and other workflow platforms.

Adaptability and flexibility:  

• Ability to prioritize tasks and manage multiple authorization cases simultaneously.

Since 2002, organizations across the entire healthcare spectrum have leveraged our deep expertise and high-quality solutions to maximize revenue, reduce operating costs and navigate the changing healthcare landscape.Medusind’s unique combination of deep industry expertise, robust operational capability, and client-focused service significantly improves the efficiency and profitability of healthcare organizations. Client satisfaction is the primary focus of the Medusind leadership and staff.Our highly experienced personnel, cutting edge technology, and forward thinking approach allows us to deliver effective solutions while staying ahead of healthcare industry changes.

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