Utilization Review Specialist

About New Horizons

New Horizons stands as the largest provider of mental health and addiction recovery services on the Treasure Coast and surrounding areas. Annually, the organization supports 15,000 children and adults through various programs including inpatient crisis services, a 24-hour helpline with mobile response, and outpatient care spread across Indian River, Martin, Okeechobee, and St. Lucie counties. Additionally, New Horizons aids 22,000 students within local schools and collaborates extensively with courts, law enforcement, jails, and hospitals to enhance individual health and community wellbeing.

Role Overview and Responsibilities

• Monitor patient accounts throughout inpatient stays and discharge phases to ensure necessary authorizations are secured and accurately logged in electronic systems.
• Promptly escalate any possible disputes or account denials to the Director of Revenue or designated personnel.
• Analyze and report denial patterns by payors to identify trends in disputed claims.
• Secure and maintain authorizations for Case Management Services in accordance with guidelines.
• Comply with all applicable federal, state, payer, and local regulations as well as accreditation standards governing case management activities.
• Follow department procedures and policies aligned with CMS Conditions of Participation and broader agency regulations.

Requirements and Preferences

• Must hold a High School diploma or equivalent qualification.
• Demonstrated organizational abilities.
• Effective verbal and written communication skills.
• Strong problem-solving capabilities.
• Proficiency with computer systems.
• Associate or Bachelor’s degree is desirable but not mandatory.
• Certifications such as Paramedic, EMT, or Nursing Assistant are preferred.
• Experience in acute hospital settings is advantageous.
• Skills in data analytics are considered an asset.