Utilization Review Specialist

The Utilization Review Specialist is a key clinical and administrative role responsible for managing the authorization process for behavioral health and substance use disorder treatment services. This position ensures that all authorization requests are clinically appropriate, timely, and aligned with the treatment plans in place for each client. The Utilization Review Specialist serves as the primary liaison between the treatment team and Managed Care Organizations (MCOs), advocating for clients to receive necessary, medically-justified levels of care.

This position requires a working knowledge of ASAM criteria and experience with levels of care including ASAM 2.1 (Intensive Outpatient), ASAM 2.5 (Partial Hospitalization), Peer Recovery Support Services, and Residential Crisis Stabilization. The ideal candidate is highly organized, technologically proficient, and able to manage competing deadlines in a fast-paced clinical environment.

Pre-Authorization & Continued Stay Reviews

• Review and submit pre-authorization requests and continued stay reviews for clinical and medical necessity across ASAM 2.1, 2.5, Peer Recovery Support Services, and Residential Crisis Stabilization.
• Ensure that all authorization requests are supported by thorough clinical documentation and align with current treatment plans.
• Verify that authorized dates of service and units received match the approved authorization upon receipt.

Authorization Management & Follow-Up

• Submit authorizations to MCOs in a timely manner, understanding the vital importance of time-sensitive submission windows.
• Actively follow up on all pending authorizations; contact MCOs by phone when authorizations are delayed to expedite processing.
• Maintain an organized tracking system for all pending, approved, and denied authorizations.

Denials Management

• Schedule and coordinate peer-to-peer reviews with MCO medical directors for any authorization denials.
• Compile and present relevant clinical documentation to support peer-to-peer discussions.

Treatment Team Collaboration

• Communicate MCO feedback, requested documentation updates, or clinical recommendations to the treatment team in a timely manner.
• Ensure that any clinical changes recommended or suggested by the MCO are acted upon by the treatment team and documented accordingly.
• Collaborate with clinical staff to confirm that treatment plans accurately reflect the level and type of care being authorized.

Documentation & Compliance

• Ensure all clinical documentation meets MCO standards and payer requirements for the applicable level of care.
• Maintain accurate and up-to-date records of all authorization activity within the electronic health record (EHR) and any payer portals.
• Stay current with payer policies, ASAM criteria updates, and regulatory requirements impacting utilization review.

• Demonstrated experience in utilization review, either on the provider side or payor side.
• Strong working knowledge of substance use disorder treatment services, including ASAM levels of care (2.1, 2.5), Peer Recovery Support Services, and Residential Crisis Stabilization.
• Familiarity with mental health crisis stabilization services and applicable clinical criteria.
• Proficiency with technology, including EHR systems, MCO authorization portals, and Microsoft Office or equivalent platforms.
• Exceptional organizational skills with the ability to manage multiple authorizations and deadlines simultaneously.
• Ability to work well under pressure and meet time-sensitive authorization requirements.
• Strong communication skills, both written and verbal, for interaction with clinical staff and MCO representatives.

Preferred

• Active licensure as an LPC (Licensed Professional Counselor), LCSW (Licensed Clinical Social Worker), LMFT (Licensed Marriage and Family Therapist), RN (Registered Nurse), or LPN (Licensed Practical Nurse).
• Prior experience with managed care organizations or insurance payers in a behavioral health context.
• Experience conducting or participating in peer-to-peer reviews with MCO medical directors.