Part-Time Utilization Specialist- OMY

General overview of key roles and responsibilities The Utilization Reviewer Specialist plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position is part-time, 20-25 hours per week and blends strong relationship-building skills with clinical expertise to navigate complex payer requirements, streamline the authorization process, and support members' and participants' transitions. This role drives the authorization process by reviewing prospective, retrospective, and concurrent Psychiatric Rehabilitation documents to secure prior authorizations by partnering with the relevant managed care team to complete concurrent review authorizations. Acting as a navigator and liaison between the OMY program and the managed care team, the Specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders. Essential & CORE Functions • Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, day authorized, and authorization numbers. • Coordinates reviews, appeals, and maintains denial logs. • Consults with appropriate treatment team members for clarification of documentation as needed. • Assist in identifying patterns of mis-utilization. • Participates in continuing education to reach professional growth objectives, including maintenance of credentials, certifications, and attending case conferences for clinical/psychiatric rehabilitation updates. • Maintains and communicates authorization information to all team members. • Monitor charts {medical records in database) for high-quality documentation when needed on a regular basis, regardless of reviews required. • Educates new staff members about Medical Necessity/Psychiatric Rehabilitation Necessity criteria, high-quality documentation, and insurance needs. • Develops relationships and rapport with payers and third-party insurance reviewers. • Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Consideration grids. • Coordinates and facilitates pre-admission Prior Authorizations for participants from referral sources. • Coordinates scheduling with Intake services for transitions in services and/or to other levels of care.. • Cross trains with Psychiatric Rehabilitation Intake Specialist for continuity of care and services delivery. Additional Responsibilities: Performs other duties and special projects as assigned. Prerequisites & Qualifications for the position: To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. This position requires individuals who are participant-focused and team-oriented, have strong interpersonal and communication skills, are flexible in the face of sudden changes in workload, emergencies, or staffing, are dependable,…