Utilization Review (UR) Specialist

Dove Recovery•Columbus, OH

3d•$75,000 - $85,000•Hybrid

About The Position

The Utilization Review (UR) Specialist is responsible for managing all aspects of authorization, continued stay requests, and utilization review activities for clients receiving treatment services. This position ensures that all clinical documentation submitted to Medicaid and commercial payers meets medical necessity standards, aligns with state and payer requirements, and supports timely approval of authorized days and service units. The UR Specialist works closely with the Clinical Director, therapists, case management, and billing teams to ensure all documentation is complete, accurate, and submitted within required timelines to maintain uninterrupted client care and maximize revenue reimbursement.

Requirements

Minimum 2 years’ experience in Utilization Review, Medicaid authorization, Behavioral Health Billing, Case Management, or similar role.
Strong knowledge of Medicaid MCO authorization portals and processes.
Familiarity with medical necessity documentation for behavioral health/SUD.
Understanding of ASAM Criteria and justification for levels of care.
Ability to read and interpret clinical notes and assessments.
Strong communication and coordination skills between clinical and billing departments.
High attention to detail and ability to meet strict deadlines.

Nice To Haves

Experience in a Substance Use Disorder or Mental Health treatment center.
Knowledge of Alleva EMR or similar EMR platforms.
CDCA, QMHS, LSW, or similar credential (not required but beneficial).

Responsibilities

Obtain initial authorizations for treatment episodes across all levels of care (PHP, IOP, SUD OP, TBS/PSR, Med Management).
Complete continued stay reviews (CSRs) and reauthorization requests by the required deadlines.
Submit Medicaid prior authorization (PA) packets including clinical documentation, notes, assessments, and treatment plans.
Monitor authorization status in payer portals and maintain communication with Medicaid MCOs (CareSource, Buckeye, Molina, Paramount, UHC, AmeriHealth, etc.).
Review clinical documentation to ensure it meets medical necessity standards required by ODM (Ohio Department of Medicaid) and payer guidelines.
Verify that progress notes, assessments, treatment plans, and signatures are complete, accurate, and compliant.
Assist clinicians in identifying documentation gaps or areas needing clarification for successful authorization.
Ensure timely collection of required documents, including: Comprehensive assessments, ASAM Level of Care justifications, Treatment plans, Progress notes, Urine drug screens, Psychiatric evaluations, Discharge summaries.
Communicate with Clinical Director and therapists regarding upcoming authorization deadlines, missing documentation, and required updates.
Collaborate with billing to ensure authorized units match billed services and resolve discrepancies.
Maintain an organized authorization tracker with start dates, end dates, units, and approvals.
Respond promptly to payer inquiries and clinical review requests.
Maintain compliance with Medicaid, ODM, CARF/Joint Commission, OhioMHAS, and payer utilization management policies.
Ensure documentation standards meet payer audits and state regulatory requirements.
Follow up on denials and submit appeals with corrected documentation when appropriate.