Utilization Review Specialist
Department: Clinical Services
Location: Remote
Reports To: Clinical Director
FLSA Designation: Exempt
JOB SUMMARY:
The Utilization Review Specialist is responsible for managing all aspects of the utilization review process, including
preauthorization, Single Case Agreements (SCA), continued authorizations, and collaboration with clinical staff to
ensure documentation meets insurance requirements. This role is crucial in securing necessary authorizations for
various levels of care, advocating for clients with insurance providers, and supporting the clinical team through training on medical necessity and documentation best practices. Work with outside agencies and third-party contractors as indicated or needed.
JOB DUTIES:
1. Preauthorization:
o Manage and submit preauthorization requests to insurance providers for clients entering treatment at
Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Standard
Outpatient (OP) levels of care.
o Ensure all required documentation is complete and accurately reflects the clinical needs of the client.
o Communicate with insurance companies to secure timely approvals for necessary services.
2. Single Case Agreements (SCAs):
o Negotiate and manage Single Case Agreements with insurance providers for clients needing services
outside of network coverage.
o Ensure that all SCAs are documented, approved, and communicated to the relevant clinical and billing
teams.
3. Continued Authorizations:
o Monitor ongoing treatment needs and submit continued authorization requests for Residential, PHP,
IOP, and OP levels of care to ensure uninterrupted client care.
o Work closely with clinical staff to gather necessary documentation, including progress notes and
updated treatment plans, to support authorization requests.
o Track authorization deadlines and follow up proactively to prevent lapses in coverage.
o Collaborate with the clinical team to ensure a comprehensive understanding of each client when asking
for continued authorization.
o Maximize the length of continued authorizations by using the comprehensive understanding of each
client when presenting to insurance companies.
4. Clinical Staff Collaboration:
o Attend regular meetings with clinical staff to discuss client progress, treatment plans, and authorization
needs.
o Provide feedback on documentation practices and suggest improvements to align with insurance
requirements.
5. Training and Education:
o Develop and deliver training sessions for clinical staff on medical necessity criteria and documentation
standards required by insurance providers.
o Create resources and guidelines for clinicians to reference when documenting client care and treatment
progress.
o Offer ongoing support and education to ensure that all clinical documentation consistently meets the
standards required for successful authorization.
6. Client Advocacy:
o Act as a liaison between clients, clinical teams, and insurance providers to advocate for the necessary
care.
o Manage and appeal authorization denials, providing additional documentation or clarification as
needed.
7. Compliance and Reporting:
o Ensure all utilization review activities comply with relevant regulations, insurance policies, and
organizational standards.
o Maintain detailed records of all authorization requests, approvals, and communications with insurance
providers.
o Generate reports on authorization success rates, SCA outcomes, and areas for improvement in the
utilization review process.
8. Complete additional tasks as assigned or needed.
MINIMUM QUALIFICATIONS:
•Education: Bachelor's degree in healthcare administration, social work, or a related field is preferred.
•Experience: At least 3-5 years of experience in utilization review, medical billing, or a related field, preferably in a
behavioral health setting.
•Skills:
o Strong understanding of insurance authorization processes, including preauthorization, continued
authorization, SCAs, and multiple levels of care.
o Excellent communication and negotiation skills with the ability to advocate effectively for client needs.
o Proficiency in electronic medical records (EMR) systems and documentation standards.
o Ability to collaborate with clinical staff and provide training on complex topics in a clear and supportive
manner.
o Detail-oriented with strong organizational and time-management skills.
PHYSICAL DEMANDS & WORKING CONDITIONS:
• The physical demands and work environment described here are representative of those that must be met by an
employee to successfully perform the essential functions of thisjob. Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential functions.
• Must be able to walk, bend, stand, climb stairs, speak English, hear, use a telephone, drive an automobile, and
operate standard office equipment, such as a computer, copier, and fax machine.
• This role may require occasional evening or weekend hours depending on client and clinical staff needs.
• The Utilization Review Specialist will work closely with the clinical team, insurance providers, and clients to ensure that all necessary authorizations are secured and maintained.
Benefits:
If you are serious about this opportunity, please submit your application and complete the below survey afterwards. The survey takes <10 minutes and is best taken on a personal computer. Those who complete the survey will be given priority.
Survey: https://go.cultureindex.com/p/EC2IEmFgTC5NI9
We are an equal opportunity employer and comply with the Americans with Disabilities Act (ADA). We are committed to providing reasonable accommodations to qualified applicants and employees with disabilities, unless doing so would cause an undue hardship. This job description outlines the essential functions of the position; individuals must be able to perform these functions, with or without reasonable accommodation, to be considered for this role.
EOE/M/F/V/D