Restriction Reviewer

State of Utah

394d • $52,686 - $83,595 • Remote

About The Position

The Restriction Reviewer position at the State of Utah involves analyzing Medicaid utilization to identify over-utilization and abuse of resources. The role requires evaluating clinical data, enrolling members in the Restriction Program, and coordinating their access to Medicaid services while ensuring compliance with relevant laws and regulations.

Requirements

• Professional education and training leading to the completion of a 2 year or longer program, culminating in a certification, registration or licensure in a medically related profession.
• Must be in current standing with a professional medical organization such as College of American Pathology (CAP), and/or the Utah Department of Professional Licensing.
• Training must specifically include a minimum of an Associate's degree (2 year) in healthcare and/or medical applications.
• 2 years' experience in a clinical setting, such as hospital, medical office, pharmacy or other acute or chronic medical care setting.
• Valid license or registry as a medical/clinical professional.
• Experience working with Excel to filter, sort and collate data.

Nice To Haves

• Bachelor of Science (4-year degree) or longer culminating in a certification, registration or licensure in a medically related profession.
• Experience working with persons who may have a substance abuse disorder and/or other mental health conditions.
• Experience working with Medicaid systems (e.g., PRISM) and/or Change Healthcare Pharmacy POS.
• Experience with Excel creating charts, graphs and formulas.

Responsibilities

• Follow Standard Operating Procedures (SOPs) to evaluate Medicaid member's utilization.
• Review claims data, medical records, pharmacy records, and other applicable sources of information representative of Medicaid utilization.
• Analyze data using professional and/or clinical judgment to make decisions regarding appropriateness of member's benefit utilization.
• Document utilization review using prescribed templates and procedures.
• Document support for decisions and conclusions reached in the analysis of medical records and claims when applying clinical judgment regarding enrollment into a Medicaid Lock-in Program or Restriction Program.
• Communicate with Medicaid members, providers, and pharmacies to coordinate appropriate medical services.
• Assist Medicaid members to resolve issues that may impede access to appropriate care and Medicaid services.
• Ensure compliance with applicable federal and/or state laws, regulations, and/or agency rules, standards, and guidelines.
• Receive, research, and respond to incoming questions or complaints; provide information, explain policy and procedures, and/or facilitate a resolution.
• Enter data into a computer system and retrieve, correct, or delete previously entered data as needed.
• Review and/or inspect work for quality, accuracy, and completeness prior to decision-making process.

Benefits

• Disability insurance
• Health insurance
• On-site gym
• Dental insurance
• Life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Executive, Legislative, and Other General Government Support
• Education Level: Associate degree