Job Summary
The Utilization Review Specialist is responsible for managing insurance utilization reviews, prior authorizations, and clinical documentation reviews to support timely access to care. The role ensures healthcare services meet medical necessity criteria, payer requirements, and regulatory standards while collaborating with providers, facilities, and internal teams to support authorization approvals and continuity of care. This position primarily supports Behavioral Health services, including Substance Use Disorder (SUD) and Mental Health programs.
Job Description
- Review clinical records and documentation to determine medical necessity and appropriateness of services.
- Conduct initial, concurrent, and continued stay reviews based on payer requirements and regulatory guidelines.
- Perform utilization reviews for Behavioral Health services, including Substance Use Disorder (SUD) and Mental Health programs, ensuring compliance with payer-specific criteria and treatment guidelines.
- Analyze utilization trends and identify opportunities to improve care delivery processes.
- Provide recommendations to support efficient utilization of healthcare services.
- Obtain prior authorizations and continued stay approvals for applicable levels of care.
- Coordinate authorization schedules with healthcare providers and insurance carriers.
- Monitor authorization periods and ensure timely submission of reviews and renewals.
- Ensure authorized services align with payer guidelines and requirements.
- Communicate with providers to obtain required clinical documentation and clarify treatment details.
- Collaborate with facility teams and internal stakeholders to support authorization processes.
- Participate in utilization review discussions and provide updates regarding authorization activities.
- Escalate authorization concerns or issues affecting patient care.
- Review denied services and assist with preparing appeals using supporting clinical documentation.
- Track and resolve authorization-related issues and discrepancies.
- Maintain accurate records of reviews, decisions, and payer communications.
- Prepare utilization review reports and documentation required by management and payers.
- Maintain compliance with HIPAA, payer requirements, and healthcare regulations.
- Stay updated on utilization review guidelines, payer policy changes, and Behavioral Health medical necessity criteria.
- Maintain confidentiality of patient health information.
- Perform additional responsibilities as assigned.
Qualifications
- Knowledge of payer requirements, medical necessity guidelines, and healthcare compliance standards.
- Experience supporting Behavioral Health services, including Substance Use Disorder (SUD) and Mental Health programs, is required.
- Proven ability to review clinical information and determine documentation completeness.
- Proven ability to communicate effectively with providers, payers, and internal teams.
- Proven ability to manage multiple reviews and deadlines in a fast-paced healthcare environment.
- Demonstrates strong analytical and problem-solving skills.
- Demonstrates strong attention to detail with excellent documentation skills.
- Demonstrates strong understanding of healthcare utilization review and authorization processes.
- Knowledge of Behavioral Health treatment levels of care, authorization workflows, and payer guidelines is highly preferred.
- Clear and coherent written and verbal communication skills in English.
Screening Criteria
- Minimum of one (1) year of experience in Utilization Review, Utilization Management, Prior Authorization, Medical Review, or Healthcare Operations.
- Minimum of one (1) year of experience supporting Behavioral Health services, including Substance Use Disorder (SUD) and Mental Health programs.
- Experience reviewing clinical documentation, obtaining prior authorizations, and coordinating with providers and insurance payers.
- Knowledge of medical necessity criteria and payer requirements for Behavioral Health services is highly preferred.
- Must have a stable employment history.
