Utilization Review

Health Care Alliance NA•Asheville, NC

16h•Remote

About The Position

The Utilization Review (UR) Specialist is responsible for managing the authorization process between HCANA facilities and third-party payers. This role ensures that all services provided—from detox to residential and intensive outpatient care—meet the criteria for medical necessity. The UR Specialist acts as a clinical advocate, utilizing clinical documentation to secure initial, concurrent, and retrospective authorizations, thereby ensuring the financial viability of the treatment provided and the continuity of care for our clients.

Requirements

High school diploma or GED
18 years of age or older.
Complete and pass pre-employment requirements, such as a background check and drug test, as outlined by HCANA policies.
Ability to set priorities, maintain accurate medical records on each client in accordance with the treatment plan and facility policies and procedures.
Strong interpersonal skills and ability to communicate with co-workers effectively and efficiently.

Nice To Haves

Prior Utilization Review or Billing experience in a substance use treatment or medical setting is a plus.
Prior experience with electronic medical records a plus, especially KIPU knowledge.
Knowledge of ASAM criteria a plus.

Responsibilities

Obtain and manage initial and concurrent authorizations for all levels of care.
Monitor authorization end-dates to ensure timely clinical reviews.
Conduct Live Reviews and Peer-to-Peer consultations with insurance company medical directors to advocate for continued stay or transitions in levels of care.
Review clinical charts (KIPU EMR) for quality and compliance.
Ensure that therapists and medical staff are documenting symptoms and progress that support medical necessity according to ASAM or other proprietary insurance criteria.
Work closely with the Admissions, Clinical, and Medical teams to communicate insurance requirements, update staff on days authorized, and flag potential denials.
Manage the appeals process for denied claims, including gathering additional clinical evidence and scheduling physician-level reviews.
Maintain accurate logs of authorized days, denial rates, and reimbursement trends.
Provide weekly reports to leadership regarding the Census vs. Authorization status.
Ensure all UR activities are conducted in strict accordance with HIPAA.