Utilization Review Clerk - Non-Exempt

Utilization Review Representative

Pay: $20-$23 per hour

The primary responsibility for the Utilization Review Rep is to be a liaison between the Utilization Review Department and the stakeholders of Embark Behavioral Health. The basic job responsibilities will be insurance authorizations (utilization review), speaking with stakeholders regarding the insurance process, submitting medical records as requested, and other duties as assigned. The Utilization Review Rep duties will include monitoring provider documentation performance, manage daily Utilization Review episodes with payors and research all “denials” with a forensic record review in a timely manner with a follow-up plan of correction. The Utilization Review Rep will ensure all documentation is following all federal and state regulations, and in accordance with Embark BH Policy and Procedures. 

The team member who joins the Utilization Review Department must be professional, a self-starter who is able to work in a fast-pace and high-stress environment, and an individual who is self-motivate with the ability to multitask well. This individual must be a team player and work well in a close environment with others. The purpose of the position is to help secure funds for Embark Behavioral Health stakeholders which increases longevity of treatment for students and families. 

Embark Behavioral Health is a unique organization comprised of extraordinary programs dedicated to bringing the current all-time high rates of adolescent anxiety, depression, and suicide to all-time lows within the decade while becoming the most recognizable, respected, and valuable behavioral health organization in the world.   

• Work with the Utilization Review Supervisor to achieveting objectives and KPIs for the Utilization Review department.  
• Ensure all potential clients receive appropriate certifications for services “to be” rendered by working closely with insurance companies, therapists and billing department. 
• Execute effective communication with clients/families and billing department. 
• Communicate regularly with the various treatment team providers. 
• Monitor the fulfillment of all documentation requirements. 
• Make recommendations to define and improve quality of processes. 
• Monitor assigned facility data reports. 
• Research all “denials” with a forensic record review in a timely manner with a follow-up plan of correction. Then implement the plan of correction with the corresponding facility heads, providers and payors for an expedient resolution. 
• Assist with on-going education for treatment team providers regarding their role in maintaining documentation standards for all clients. 
• Collect information for communication with insurance or other funding sources. 
• Interface with managed care organizations, external reviews and other payors. 

• Completion of pre-authorizations to Medicaid and other third parties as required. 
• Submission of retrospective review requests to insurance companies as required. 
• Fulfilling all medical records requests to various individuals and entities on the assigned caseload. 
• Other duties as assigned and appropriate. 

• High School/GED required, Associate degree preferred 
• Customer Service experience required with residential treatment experience preferred 
• Experience with insurance utilization review process and medical terminology; previous utilization review experience in a behavioral health or psychiatric healthcare facility preferred. 
• HIPAA Certification required upon employment 
• Ability to maintain confidentiality in compliance with HIPPA Guidelines 
• Familiarity with medical terminology, diagnostic terms, and treatment modalities. 
• Working knowledge of Windows-based applications, including Outlook, Word and Excel 
• Hands-on experience with accounting software and familiarity with MS Excel to include strong analytical skills 
• Strong and professional communication skills 
• Skilled in negotiation and problem-solving aptitude 
• Patience and ability to manage stress and maintain confidentiality 
• Ability to apply state and federal laws, regulations, and policies governing utilization review. 
• Strong written and verbal communication skills 
• Exceptional organizational skills and attention to detail 

• Self-starter, self-sufficient, self-confident leading to an ability to create a system for medical records and communication with Embark families in multiple programs 

• Enjoy a comprehensive Benefits Program, encompassing medical insurance with a generous company contribution towards a high deductible plan, dental insurance, vision insurance, voluntary life and AD&D insurance, long-term disability, 401K with company matching, and paid maternal leave.
• Revel in the balance of Company Paid Holidays and a PTO accrual schedule.
• At Embark, we and our team members embody core values of empathy, trusting relationships, service, growth, and results. Join us in making a meaningful difference.

Embark is an Equal Employment Opportunity Employer. Embark is committed to enriching the therapeutic and healing experience it offers through the diversity of its employees and community. Embark seeks to recruit and support a broadly diverse staff who will contribute to the organization's excellence, diversity of viewpoints and experiences, and relevance in a global society.