Utilization Review Specialist (in-office only)

Quadrant Health Group • Boca Raton, FL

15d • $55,000 - $70,000 • Onsite

About The Position

Quadrant Billing Solutions, a member of Quadrant Health Group, is expanding and seeking a Utilization Review Specialist. They offer boutique medical billing specifically for substance abuse and mental health treatment. The ideal candidate will have 3+ years of clinical experience and a strong desire to contribute to a dynamic, fast-paced & results driven environment. This role is for someone ready to learn a structured system involving timely payer outreach, clean documentation, consistent follow-up, and strong coordination with clinical teams. The UR Specialist plays a critical role in ensuring both clinical quality management and financial viability for partner facilities, bridging the gap between clinical care and revenue cycle management. They serve as the direct liaison between facility clinical teams, insurance providers, and the billing department, ensuring seamless communication, accurate documentation, and optimal patient outcomes. This is an in-office position in Boca Raton, FL.

Requirements

• 3+ years of clinical experience
• Prior UR experience
• Ability to be aggressive in advocating on behalf of our facilities to insurance carries
• Ability to communicate effectively with clinical team to understand treatment needs of patients
• Understanding of their role in a multi-disciplinary team
• Ability to provide detailed feedback and Clinical Quality management to all assigned facilities
• Always communicate in a professional manner in both verbal and written communication internally and with our facility’s
• Being focused throughout the day while staying organized and maintaining attention to detail
• Able to manage a minimum caseload of between 30-50 patients
• Strong working knowledge of ASAM & LOCUS criteria
• Work collaboratively with insurance providers
• Be proficient with using various EMR software (must have experience with Kipu)
• Exceptional customer service and both verbal and written communications skills
• Ability to grow and foster relationships with care managers as well as clinicians at the facilities
• Must be a team player
• Attention to detail and must be organized
• Minimum 2 year experience in utilization review
• Minimum 4 years of experience in substance abuse or mental health treatment

Nice To Haves

• Bachelors degree preferred

Responsibilities

• Serve as a strong patient advocate, effectively communicating clinical justifications to insurance payers.
• Apply medical necessity criteria to secure initial and continued authorizations across all levels of care.
• Utilize problem-solving and critical thinking to navigate complex authorization issues and minimize denials.
• Work closely with clinical teams to ensure treatment plans align with insurance criteria for continued authorization.
• Provide ongoing feedback to facilities regarding documentation improvements, level of care justifications, and payer trends.
• Serve as the primary point of contact between facilities and the billing team, ensuring smooth coordination and timely approvals.
• Proactively educate and guide facilities on insurance requirements, helping them adapt to payer expectations.
• Maintain clear, professional, and proactive communication with facility staff, insurance representatives, and internal billing teams.
• Manage a caseload of 50-70 patients, ensuring timely follow-ups, thorough documentation, and strong attention to detail.
• Document all interactions in the EMR (Kipu experience required) and ensure all authorization trackers are up to date.
• Ensure that denied or pended cases are escalated appropriately through peer reviews or appeals.
• Efficiently navigate EMR systems (Kipu experience required).
• Utilize Google Docs, Google Sheets, and Google Drive for internal reporting, tracking, and collaboration.
• Assist in after-hours utilization reviews as needed to prevent service disruptions and maintain compliance.
• Adapt quickly to payer policy changes and ensure facilities are informed of updates that impact clinical documentation and authorization processes.
• Track authorization start/end dates to prevent lapses in coverage.
• Document payer interactions, reference numbers, and determinations clearly.
• Coordinate with clinical staff and admissions teams to ensure payer needs are met quickly.
• Follow established UR workflows and receive ongoing training and coaching.
• Support continuous improvement through accuracy and consistent execution.
• Be willing to multitask.
• Handle reviews after standard business hours as needed.
• Be proficient in Google docs, Google word, and utilizing Google drive.

Benefits

• Competitive salary commensurate with experience.
• Comprehensive benefits package, including medical, dental, and vision insurance.
• Paid time off, sick time and holidays.
• Opportunities for professional development and growth.
• A supportive and collaborative work environment.
• A chance to make a meaningful impact on the lives of our clients.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED