Job Purpose: The Utilization Review Specialist ensures that all services provided to patients meet payer requirements for medical necessity and authorization. This role is responsible for obtaining and maintaining authorizations, submitting clinical documentation, preventing avoidable denials, and supporting optimal reimbursement for the organization. The UR Specialist works closely with clinical teams, admissions, and billing to ensure continuity of care and compliance with payer guidelines.
Primary Responsibilities:
Obtain initial authorizations for all new admissions
Submit concurrent reviews and continued‑stay requests within required timelines
Track authorization dates, units, and expiration deadlines
Communicate authorization status to clinical, billing, and admissions teams
Review clinical notes to ensure they meet payer medical‑necessity criteria
Request additional documentation from clinicians when needed
Prepare and submit clinical summaries to payers
Conduct timely follow‑up calls with insurance companies
Clarify payer requirements and communicate updates to internal teams
Maintain professional, accurate documentation of all payer interactions
Identify trends in authorization denials and collaborate on solutions
Assist billing team with clinical information needed for appeals
Participate in denial‑prevention initiatives and process improvements
Partner with Admissions to confirm insurance requirements before admission
Work with Billing to ensure accurate claim submission
Communicate with Clinical Leadership regarding documentation quality
Ensure all UR activities comply with payer guidelines and internal SOPs
Maintain HIPAA compliance at all times
Participate in audits and quality‑improvement initiatives
Experience in utilization review, case management, or behavioral health billing preferred
Strong understanding of medical necessity criteria (ASAM, DSM‑5, payer guidelines)
Excellent communication and documentation skills
Ability to work in a fast‑paced environment with strict deadlines
Proficiency with EHR systems and payer portals
Education and experience, degree and/or certification required (if applicable):
Education and Experience:
High school diploma or equivalent required; associate’s or bachelor’s degree in business, finance, or related fields preferred.
Minimum of 2 years of experience in substance/behavioral health, ASAM, or clinical related fields.
Skills and Abilities:
Strong understanding of utilization review, ASAM criteria.
Familiarity with electronic medical records (EMR) and billing software.
Understands payer medical‑necessity standards
Can interpret clinical documentation for UR purposes
Identifies when documentation is insufficient
Excellent analytical, organizational, and problem-solving skills.
Strong communication skills, both verbal and written.
Ability to work independently and manage multiple tasks effectively.
Working Relationships:
As a representative of Freeman Solutions, LLC, all comments, actions and behaviors have a direct effect on Freeman Solutions, LLC and its image and perception of quality care for the individuals we serve. Interactions with patient(s), staff, referral sources, guests and visitors, volunteer(s), and supervisors must be in a manner that is friendly, supportive, courteous, respectful and professional. This behavior should promote an atmosphere of teamwork that is congruent with Freeman Solutions, LLC policies and procedures and set a standard and guideline to promote positive relations.
I have read the above job description and agree to perform the responsibilities as described above. I understand that this job description is intended to describe the general nature and level of work performed. It is not intended to serve as an exhaustive list of all duties, skills and responsibilities required.