Utilization Review Specialist
About The Position
The Utilization Review Specialist serves as a link between the clinical treatment team, patients, and insurance providers. The role coordinates clinical reviews and insurance authorizations, advocates for appropriate behavioral healthcare, and ensures treatment decisions are supported by clinical documentation. The specialist works with a multidisciplinary team and with insurers and other payers to support medically necessary inpatient and outpatient care, including care for substance use disorders, psychiatric conditions, and dual diagnoses. This position is intended for a motivated healthcare professional interested in patient advocacy, clinical care, healthcare administration, and insurance processes. The employee will learn clinical review standards and authorization requirements while developing professional skills within an established behavioral healthcare organization.
Requirements
- Bachelor’s degree required.
- Strong written and verbal communication skills.
- Excellent attention to detail and organizational skills.
- Ability to manage competing priorities and collaborate with clinical professionals, insurance representatives, and other stakeholders.
- Willingness to learn clinical review standards, insurance authorization requirements, and applicable guidelines.
- Flexibility to work additional hours when business needs require.
Nice To Haves
- Master’s degree preferred.
- Current, unencumbered clinical license strongly preferred.
- CPR certification preferred.
- Crisis Prevention Training (CPI) preferred.
Responsibilities
- Coordinate clinical reviews for patient admissions and continued stays, ensuring information is available to support medical necessity and treatment decisions.
- Review patient records and clinical documentation to evaluate the appropriateness of admissions, treatment plans, and lengths of stay.
- Work with insurance companies, managed care organizations, external reviewers, and other payers to obtain authorizations for inpatient and outpatient services.
- Advocate for patients receiving behavioral healthcare to help secure coverage for medically necessary care.
- Collaborate with physicians, nurses, therapists, and other interdisciplinary team members to communicate authorization requirements and coordinate care.
- Help the treatment team understand insurance requirements affecting continued treatment, transitions of care, and discharge planning.
- Complete pre-certifications, re-certifications, and clinical reviews accurately and within established timeframes.
- Coordinate peer-to-peer reviews between physicians and insurance representatives when necessary.
- Assist with insurance denials and appeals, ensuring supporting clinical documentation is complete and submitted promptly.
- Work with nursing leadership to help ensure clinical documentation meets applicable requirements.
- Maintain accurate records and communicate authorization updates, denials, and other relevant information to designated team members.
Benefits
- Multiple levels of medical, dental, and vision coverage for eligible full-time and part-time employees.
- Life, accident, critical illness, and hospital indemnity insurance.
- Short- and long-term disability.
- Paid family leave and paid time off.
- Tuition assistance for higher education and professional certifications.
- Loan assistance.
- Continued learning and career development opportunities.
- 401(k) retirement savings plan with company matching.
- Mental, physical, and financial wellness programs.
- Free gym memberships.
- Virtual care appointments.
- Mental health services.
- Employee discount programs.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
