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

Role Description

We are seeking a Utilization Review Specialist to add to our dynamic team! The Utilization Review Specialist 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.

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with payer requirements and established departmental workflows.
• Obtain, document, and monitor authorizations across the continuum of care, including approved level of care, number of units or days, effective dates, review dates, authorization numbers, and payer-specific conditions.
• Review the medical record and collaborate with the treatment team to obtain complete, accurate, and timely clinical information supporting medical necessity and the requested level of care.
• Present clinical information to payer representatives clearly, objectively, and persuasively, 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 daily; complete required 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 regarding anticipated transitions, discharge planning, and changes in level of care 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 escalation activities 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 professionally 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 ensure compliance 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.

Qualifications

• High school diploma or equivalent required; relevant college coursework, professional certification, or equivalent directly related experience strongly preferred.
• Minimum 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.
• Demonstrated ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation.
• 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.

Preferred Qualifications

• Bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or a related healthcare discipline.
• Minimum 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.

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.