Utilization Review Manager

Brief Description

Utilization Review Manager - Exact Billing Solutions

Lauderdale Lakes, FL

About Exact Billing Solutions

Exact Billing Solutions is a unique team of medical billing professionals specializing in the substance use disorder, mental health, and autism fields of healthcare services. We have extensive industry knowledge, a deep understanding of the specific challenges of these markets, and a reputation for innovation. With our proprietary billing process, EBS is the oil that brings life to the engines of its partner healthcare companies.

Leadership Opportunity

If you're a BCBA or an experienced leader in healthcare with utilization review knowledge looking for something different from the same old hospital/clinic routine, you could be our Utilization Review Manager.

The Utilization Review Manager (ABA) is responsible for overseeing the utilization review process for Applied Behavior Analysis (ABA) therapy services. This leadership role involves managing a team of utilization review specialists, ensuring compliance with regulatory requirements, and optimizing the allocation of resources to deliver effective and efficient ABA therapy. The Utilization Review Manager works closely with clinical staff, insurance providers, and other healthcare professionals to ensure that ABA services meet medical necessity criteria, align with best practices, and support optimal patient outcomes.

What You'll Do

Oversight of Utilization Review Process

• Lead, manage, and monitor the daily operations of the utilization review team to ensure the timely and accurate review of ABA treatment plans and services.
• Develop and implement utilization review policies and procedures to ensure the delivery of ABA therapy services meets regulatory, clinical, and payer standards.
• Ensure that all utilization reviews are conducted in a manner that is efficient, accurate, and consistent with clinical guidelines, payer requirements, and best practices in ABA therapy.
  
  

• Supervise, train, and mentor utilization review specialists and other staff involved in the review process, providing guidance and support to ensure high-quality reviews.
• Conduct regular performance evaluations, identify areas for improvement, and provide ongoing professional development opportunities for the utilization review team.
• Ensure that team members stay current with changes in insurance policies, payer requirements, and healthcare regulations related to ABA therapy.
  
  

• Work closely with behavior analysts, clinicians, and other healthcare professionals to ensure that ABA therapy treatment plans meet medical necessity and comply with insurance and regulatory requirements.
• Facilitate collaboration between the utilization review team and other departments, including billing, case management, and insurance liaisons, to resolve issues and ensure timely authorizations.
• Provide feedback to clinical teams about treatment plan modifications, documentation improvements, and areas for clinical growth based on utilization review findings.
  
  

• Oversee the communication and coordination with insurance companies, ensuring that ABA therapy services are authorized in a timely manner and in line with payer requirements.
• Lead efforts to manage insurance denials, appeals, and authorizations, working with clinical teams to provide necessary documentation and justifications for continued care.
• Keep abreast of changes in insurance policies and payer regulations to ensure compliance and adjust review processes as needed.
  
  

• Ensure compliance with federal, state, and local regulations, as well as payer-specific requirements, in the utilization review process for ABA services.
• Regularly audit UR specialists' documentation to ensure high standards of quality and compliance are maintained.
• Monitor trends in service utilization and identify opportunities for improving the efficiency and effectiveness of ABA therapy services.
• Report on key metrics, including utilization trends, approval rates, and the resolution of denials, to leadership and stakeholders.
  
  

• Analyze utilization data to identify patterns, trends, and areas of opportunity for improving resource allocation and patient care.
• Prepare and present regular reports on the status of utilization review activities, including treatment authorizations, appeals, denials, and compliance audits.
• Maintain detailed records of utilization review findings, decisions, and communications with payers, clinicians, and patients.
  
  

• Lead process improvement initiatives aimed at enhancing the efficiency, accuracy, and effectiveness of the utilization review process.
• Contribute to strategic planning for the organization's ABA therapy services, ensuring alignment with clinical goals, patient needs, and payer requirements.
• Implement best practices for utilization management to ensure the delivery of high-quality, cost-effective care to patients.
  
  

• Master's degree in behavioral health, psychology, social work, nursing, or a related clinical field.
• Board Certified Behavior Analyst (BCBA) certification is preferred.
• Certification in Utilization Review (e.g., Certified Professional in Utilization Review (CPUR)) is highly desirable.
• 5+ years of experience in ABA therapy, utilization review, or related healthcare management.
• 2+ years of supervisory or managerial experience in a clinical or healthcare setting.
• Strong background in working with insurance companies, understanding medical necessity criteria, and managing payor authorizations and denials.
• In-depth knowledge of ABA therapy principles, techniques, and treatment modalities.
• Comprehensive understanding of insurance policies, utilization review processes, and regulatory compliance requirements.
• Willingness to submit to drug and background screenings.
  
  

• Strong leadership and team management skills, with the ability to guide and motivate a team.
• Excellent communication skills, including the ability to interact effectively with clinicians, insurance companies, patients, and families.
• Strong analytical skills, with the ability to interpret data and generate actionable insights.
• Detail-oriented with the ability to manage multiple tasks and competing priorities in a fast-paced environment.
• Proficiency in using electronic health records (EHR), utilization review software, and Microsoft Office applications.