UR Specialist

Enterhealth • Van Alstyne, TX

1d

About The Position

The Utilization Review plays a critical role in ensuring effective coordination of care, clinical documentation accuracy, and insurance authorization compliance. This role acts as a liaison between clinical staff, insurance providers, clients, and their families, ensuring that services are medically necessary, properly documented, and that discharge planning begins at the time of admission. Utilization Review: Conduct regular reviews of clinical documentation to ensure compliance with payer requirements and medical necessity criteria (e.g., ASAM, MCG, InterQual). Submit initial and concurrent insurance authorizations for residential, PHP, and IOP levels of care. Communicate with insurance case managers and update them on client progress. Maintain accurate records of authorizations, denials, and appeals. Collaborate with clinicians and medical providers to gather necessary clinical updates. Collaboration & Compliance: Maintain confidentiality in accordance with HIPAA, 42 CFR Part 2, and all regulatory guidelines. Support quality assurance initiatives and audits related to documentation. Serve as a key contact for insurance utilization audits and reviews. Qualifications: Education: Bachelor's degree in Nursing, Social Work, Psychology, or related field required. Experience: 2+ years of experience in a behavioral health or addiction treatment setting. Prior utilization review experience strongly preferred. Licensure/Certification: RN, LVN, LBSW, LMSW, LMFT or LPC-A, or equivalent credential preferred. Skills: Strong organizational and communication skills. Ability to manage multiple priorities and timelines. Proficient in EHR systems and insurance portals. Proficient in Electronic Medical Records (EMR) systems Competencies Effective communication across all levels, including management, staff, and patients, using both written and verbal skills Exceptional customer service abilities, including active listening and patient-centered care Proficiency in computer applications, including data entry, word processing, Microsoft Outlook, and Excel Strong critical thinking and decisive judgment skills Ability to work independently in a fast-paced environment with minimal supervision EQUAL OPPORTUNITY EMPLOYER : Enterhealth provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. PHYSICAL REQUIREMENTS : The physical demands outlined below represent those necessary for an employee to successfully perform the essential functions of this role: Regularly required to sit, use hands for handling or feeling, and communicate effectively through speech and hearing. Frequently required to reach with hands and arms. Occasionally required to stand and walk. Specific vision requirements include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. This role involves light physical demands. WORKING CONDITIONS : The work environment is representative of a typical office or administrative setting. Employees can expect a generally quiet atmosphere with a low noise level while performing the essential functions of this role.

Requirements

• Bachelor's degree in Nursing, Social Work, Psychology, or related field required.
• 2+ years of experience in a behavioral health or addiction treatment setting.
• Strong organizational and communication skills.
• Ability to manage multiple priorities and timelines.
• Proficient in EHR systems and insurance portals.
• Proficient in Electronic Medical Records (EMR) systems
• Effective communication across all levels, including management, staff, and patients, using both written and verbal skills
• Exceptional customer service abilities, including active listening and patient-centered care
• Proficiency in computer applications, including data entry, word processing, Microsoft Outlook, and Excel
• Strong critical thinking and decisive judgment skills
• Ability to work independently in a fast-paced environment with minimal supervision

Nice To Haves

• Prior utilization review experience strongly preferred.
• RN, LVN, LBSW, LMSW, LMFT or LPC-A, or equivalent credential preferred.

Responsibilities

• Conduct regular reviews of clinical documentation to ensure compliance with payer requirements and medical necessity criteria (e.g., ASAM, MCG, InterQual).
• Submit initial and concurrent insurance authorizations for residential, PHP, and IOP levels of care.
• Communicate with insurance case managers and update them on client progress.
• Maintain accurate records of authorizations, denials, and appeals.
• Collaborate with clinicians and medical providers to gather necessary clinical updates.
• Maintain confidentiality in accordance with HIPAA, 42 CFR Part 2, and all regulatory guidelines.
• Support quality assurance initiatives and audits related to documentation.
• Serve as a key contact for insurance utilization audits and reviews.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level