Utilization Review Specialist

ADDICTION AND MENTAL HEALTH SERVICES • Birmingham, AL

20h

About The Position

Bradford Health Services is seeking a Utilization Review Specialist to support its addiction treatment programs. The position evaluates patient records, treatment plans, and clinical data to determine whether care is medically necessary, efficient, and compliant with payer and regulatory requirements. The specialist works with healthcare providers, insurance companies, case managers, and internal teams to obtain timely authorizations and support appropriate patient care and resource utilization.

The role manages utilization reviews and authorization activity across the continuum of care. It requires interpreting clinical documentation, communicating medical-necessity information to payers, tracking deadlines and authorization conditions, identifying documentation gaps, and escalating potential denials or other barriers. The specialist also supports appeals, quality activities, and performance improvement while protecting confidential patient information and following organizational and regulatory requirements.

Requirements

• High school diploma or equivalent required.
• At least 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related function.
• Behavioral health and/or substance use disorder experience required.
• Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up.
• Ability to interpret clinical documentation and clearly communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge.
• Ability to manage multiple cases, payer deadlines, and competing priorities accurately and escalate issues appropriately.
• Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality.
• Working knowledge of HIPAA and 42 CFR Part 2 requirements.

Nice To Haves

• Relevant college coursework, professional certification, or equivalent directly related experience.
• Bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or a related healthcare discipline.
• At least 1 year of direct utilization review, concurrent review, or payer authorization experience within behavioral health or substance use disorder treatment.
• Knowledge of ASAM Criteria and experience with residential, inpatient, partial hospitalization, intensive outpatient, and outpatient levels of care.
• Experience working with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers.
• Experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals.
• Active clinical license or relevant certification, such as RN, LPN/LVN, LMSW, LPC, CADC, LADAC, CCM, or an equivalent credential; preferred but not required.
• Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications.

Responsibilities

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with payer requirements and departmental workflows.
• Obtain, document, and monitor authorizations across the continuum of care, including level of care, approved units or days, effective dates, review dates, authorization numbers, and payer-specific conditions.
• Review medical records and collaborate with treatment teams to obtain complete, accurate, and timely clinical information supporting medical necessity and the requested level of care.
• Present clinical information clearly and persuasively to payer representatives using applicable medical-necessity criteria and payer guidelines.
• Maintain accurate authorization records in the electronic medical record, payer portals, tracking systems, and other designated applications.
• Monitor assigned caseloads and authorization deadlines, complete follow-up, and escalate unresolved payer, documentation, or authorization barriers before reimbursement is placed at risk.
• Identify clinical documentation gaps or inconsistencies and communicate specific needs to the appropriate clinician, provider, or leader without directing clinical care or altering the clinical record.
• Coordinate with clinical and case-management teams on anticipated transitions, discharge planning, and level-of-care changes to support continuity of treatment and timely payer notification.
• Recognize potential adverse determinations and promptly escalate cases requiring peer-to-peer review, reconsideration, appeal, or leadership intervention.
• Prepare concise case summaries and supporting documentation for peer reviews, appeals, and other payer escalations as assigned.
• Review payer correspondence and adverse determinations for accuracy, communicate outcomes to appropriate stakeholders, and complete required follow-up within established deadlines.
• Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives.
• Follow standardized utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states.
• Maintain working knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and assigned service-line requirements.
• Collaborate with Utilization Review leadership, Centralized Admissions, Clinical Directors, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and other Revenue Cycle partners.
• Protect patient privacy and comply with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies.
• Perform other duties as assigned in support of Utilization Review and Revenue Cycle objectives.

Benefits

• Medical coverage with three BCBSAL medical plans, improved rates and co-pays, and enhanced prescription benefits.
• Expanded coverage options for domestic partners and access to a wider network of in-network providers.
• Mental health support, including improved access to services and an Employee Assistance Program with digital wellness tools and wellness coaching.
• Voluntary coverages including pet insurance, home and auto insurance, and family legal services.
• Student loan repayment available for nurses and therapists.
• 401(k) plan through Voya.
• Generous paid time off.
• Voluntary dental, vision, life, accident insurance, and telehealth options for part-time employees working 20 hours or more per week.

What This Job Offers

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