[Hiring] Utilization Review Specialist - Mental Health/Behavioral @Pro Med Healthcare Services

Role Description

The UR Specialist is responsible for reviewing clinical documentation to ensure medical necessity, appropriate level of care, and compliance with payer and regulatory requirements. This role works closely with clinical staff, admissions, and insurance providers to support timely authorizations, continued stay reviews, and quality patient care.

• Review patient records to verify medical necessity and appropriateness of services.
• Conduct initial and concurrent reviews with insurance companies to obtain authorizations.
• Prepare and submit clinical documentation for continued stay requests.
• Track authorization status and maintain accurate documentation in the medical record.
• Communicate effectively with clinical teams to obtain required information.
• Assist with denial management and appeals as needed.
• Ensure compliance with state, federal, and accreditation requirements (e.g., CARF, AHCA, DCF, etc.).
• Maintain confidentiality of all patient and organizational information.

Qualifications

• Bachelor’s degree in Mental Health, Social Work, Psychology, or related field (or equivalent experience).
• 2 years of previous experience in utilization review or insurance authorization preferred.
• Strong knowledge of medical necessity criteria (e.g., ASAM, LOCUS, InterQual).
• Excellent communication, organizational, and time management skills.
• Proficiency in electronic health records and Microsoft Office Suite.

Company Description