Utilization Review Manager

GRO Community•Chicago, IL

16d

About The Position

The Utilization Review Manager (URM) is responsible for coordinating and monitoring clinical documentation and service authorizations to ensure medical necessity, regulatory compliance, and optimal reimbursement. This role serves as a key liaison between clinical staff, payers, and administrative teams to support timely and accurate utilization management while maintaining quality-of-care standards. The URS will also facilitate utilization review processes across departments and coordinate appropriate client step-downs when clinically indicated.

Requirements

Masters degree in Nursing, Psychology, Social Work, Health Administration, or related field required
Minimum 3–5 years of utilization review, case management, or clinical documentation experience in a healthcare, behavioral health, or managed care environment.
Strong knowledge of insurance authorization processes and payer criteria.
Excellent analytical and communication skills.
High attention to detail and ability to manage multiple cases simultaneously.
Proficiency in EHR systems and Google Office Suite.

Nice To Haves

Active LCSW or LCPC clinical licensure highly preferred.

Responsibilities

Conduct ongoing utilization reviews of client treatment plans, progress notes, and service delivery to ensure alignment with payer and regulatory requirements.
Coordinate with insurance companies by submitting all required documentation and addressing any disputes or discrepancies.
Submit, track, and follow up on initial and continued service authorization requests with insurance carriers and funding sources.
Monitor and analyze denial trends, proactively identifying opportunities to improve documentation and authorization processes.
Maintain detailed records of authorization status, denials, and appeal outcomes.
Collaborate with clinicians to ensure treatment plans, assessments, and progress notes meet clinical and payer criteria.
Provide guidance and training to staff on documentation standards related to utilization review and medical necessity.
Participate in internal audits and assist in developing corrective action plans when deficiencies are identified.
Serve as the primary point of contact for payer representatives regarding authorizations, reauthorizations, and claims-related issues.
Partner with the revenue cycle team to reconcile service utilization against approved authorizations.
Work closely with Clinical Operations and Counseling supervisors to monitor caseload utilization and prevent service gaps or overages.
Ensure adherence to HIPAA, Medicaid, and managed care regulations.
Maintain up-to-date knowledge of payer requirements, industry standards, and policy changes affecting utilization management.
Prepare and present utilization and authorization reports to leadership, identifying patterns and recommendations for improvement.