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From direct care staff to program managers to clinicians, our employees make a difference every day. Our talented team helps individuals with intellectual and developmental disabilities thrive in the communities they call home. And as part of The MENTOR Network— a national network of local health and human services providers—REM’s employees are part of a growing organization that’s been at the forefront of providing innovative, community-based care for more than 30 years

Utilization Review Specialist

Job ID 17000N1Z
Description
Utilization Review Specialist
Primary Location: United States-WV-WVMartinsburg
Function:Program Services Coordination/Case Management
Organization:Redwood

REM Community Options
Description
Every person needs the support of others, but we look for very special people to support individuals with disabilities; children with emotional, behavioral or medical complexities; children and adults with brain injury). As a Utilization Review Specialist with (REM Community Options) you’ll be one of those special people.
   
(REM Community Options) is seeking a Utilization Review Specialist to be responsible for proactive planning measures, accurate documentation of services delivered for audit assurances, and positive outcomes regarding effective service utilization to customers. This role will provide professional oversight of service delivery authorizations and assurances, effective tracking and timely recommendations in regards to service delivery utilization parameters, and quality assurance of service delivery records on an ongoing basis. The Utilization Review Specialist manages at least two full time employees.
 
Essential Job Functions
  • Proactively develops plans to accurately measure documentation of services delivered to assure compliance with auditors.
  • Oversees service delivery authorizations and assurances, recommends service delivery utilization parameters, and provides quality assurance of service delivery records.
  • Provides ongoing technical assistance to clinical staff in the service areas of; facilitation of timely and appropriate service authorization, effective monitoring strategies and report analysis of actual service deliveries in comparison to authorized service approvals (type, units, dollars, etc).
  • Analyzes the over/under delivery of services, and consistent coordination of required service documentation along with corresponding billing tickets. Maintains organized and complete records and assures quality focused service delivery method strategies.
  • Effectively tracks and assures that current and approved Individual Service Plan(s) appropriately correspond and match areas of support services and service delivery documentation records.
  • Completes weekly, bi-weekly, and monthly reviews of all service delivery documentation and corresponding billing ticket/pre invoice submitted by program staff for processing; verifies completeness of required information.
  • Assures and maintains functional knowledge base and materials related to current and new funding Rules and Contracts, provides updates and information to supervisor and/others specific to impact on service delivery, authorizations, and utilization of services.
  • Responsible for establishing and monitoring the regional office and storage filing systems to assure information is organized, complete, and retrievable for compliance audit file reviews.
  • Performs other related duties and activities as required.

Qualifications:
Requirements:
  • High School Diploma or equivalency degree 

Founded in 1980, The MENTOR Network is a national network of local human services providers offering an array of quality, community-based services in more than 30 states to adults and children with intellectual and developmental disabilities, brain and spinal cord injuries and other catastrophic injuries and illnesses, and to youth with emotional, behavioral and medically complex challenges as well as their families.

EOE/AAE

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