Utilization Review Specialist

Lighthouse Behavioral Health Solutions•Columbus, OH

2h•Onsite

About The Position

The Utilization Review (UR) Specialist is responsible for ensuring that clients receiving substance use disorder (SUD) treatment services meet clinical criteria for admission, continued stay, and discharge. This role supports compliance with payer requirements, maintains proper documentation, and collaborates with clinical and administrative teams to maximize reimbursement while ensuring high-quality, medically necessary care.

Requirements

Bachelor’s degree in behavioral health, nursing, social work, or a related field required.
Knowledge of ASAM Criteria required
Minimum of 1 year of experience in utilization review, case management, or clinical services within behavioral health or SUD treatment
Familiarity with electronic health record (EHR) systems
Must pass BCI check, all Corporate Compliance checks, and employment drug screen

Nice To Haves

Experience working with commercial insurance, Medicaid, and/or Medicare preferred
Master’s degree or clinical licensure (e.g., LSW, LPC, LCSW, RN) preferred.
3 years in a supervisory or management role within a behavioral health setting
Working knowledge of CPT and ICD-10 coding systems, with relevant certification (e.g., CPC, CCS-P) or equivalent experience
Understanding of medical necessity criteria, including experience with InterQual and/or Milliman (MCG) guidelines

Responsibilities

Conduct initial and concurrent reviews to determine medical necessity using established criteria
Submit authorization requests and clinical documentation to insurance providers in a timely manner
Monitor authorizations and ensure services rendered align with approved levels of care
Track and manage authorization expirations and initiate reauthorization requests as needed
Review clinical records for completeness, accuracy, and compliance with payer and regulatory standards
Ensure treatment plans, progress notes, and discharge summaries support medical necessity
Provide feedback to clinical staff to improve documentation quality
Maintain adherence to HIPAA and confidentiality regulations
Serve as the primary liaison between the organization and insurance companies for utilization review matters
Participate in peer-to-peer reviews when required
Address denials by gathering supporting documentation and submitting appeals
Stay current with payer guidelines and regulatory changes affecting SUD services
Collaborate with clinical, admissions, billing, and case management teams to ensure continuity of care and proper utilization of services
Participate in multidisciplinary team meetings to discuss patient progress and level-of-care needs
Communicate authorization status and payer requirements to relevant staff
Maintain accurate records of authorizations, denials, and appeals
Track utilization metrics and identify trends to improve efficiency and reimbursement
Participate in audits and quality assurance initiatives
Perform other duties as assigned