[Hiring] Utilization Review Manager @ADDICTION AND MENTAL HEALTH SERVICES, LLC

Role Description

We are seeking a Utilization Review Manager to add to our dynamic team! The Utilization Review Manager plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care.

• Oversee the coordination of the facility's insurance certification including precertification and continued stay reviews, as well as ensure all insurance denials, appeals, and reconsiderations are completed in a timely manner.
• Know and abide by the general provisions of 42 CFR Part 2, “Confidentiality of Drug and Alcohol Abuse Patient Records”, and 45 CFR “Health Insurance Portability and Accountability Act.” This position has unrestricted access to patient identifying and patient health information.
• Coordinate and manage the day-to-day activities of the Utilization Review Staff.
• Complete daily reports and assign cases to the Utilization Coordinators, as well as coordinate with other departments as needed to complete the Utilization Review process.
• Ensure maintenance of "UR Activity Log", which records every review for the facility with financial classification and U.R. information/activity.
• Fill in as needed, or re-assign activities, to make sure all pre-certifications and continued stay reviews are completed in a timely manner.
• Review and maintain any correspondence pertaining to certification, appeals, denials, or reconsiderations.
• Complete all Quality Improvement indicators for Utilization Management and report those indicators at the quarterly PIC meeting.
• Educate Counseling staff regarding documentation of patient care; and educate Crisis staff regarding intake assessments.
• Participate in the hiring, training, and evaluation of staff as necessary.
• Ability to work in a constant state of alertness as to perform the job safely.
• Ability to work in a cooperative manner with co-workers, managers, clients, and prospective managers.
• Regular attendance.
• Any other duties assigned by supervisor.

Qualifications

• Must have a current RN, LPC or LCSW license.
• Two years minimum experience in utilization review.
• Must possess good grammatical and communication skills.
• Must be skilled in Microsoft Office applications and have a working knowledge of office equipment.
• Must be able to see and read handwritten or printed notes and hear and/or interpret instructions (with or without corrective devices).
• Must be able to continuously sit for approximately 7 hrs. per 8 hr. shift.
• Must be able to walk within the facility a total of approximately two (2) hrs. per day.
• Must be emotionally and physically capable of functioning under stressful situations.
• If recovering, two years of continuous verifiable abstinence.

Benefits

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
• Student Loan Repayment – Available for nurses and therapists.
• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
• Generous PTO – A robust paid time off policy to support work-life balance.
• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.