Utilization Review Specialist

The Utilization Review Specialist performs insurance authorizations and retrospective reviews for patients in substance use treatment. This position focuses on conducting insurance authorization requests, managing retro authorizations, tracking ongoing reviews, and ensuring timely submission of all necessary documentation to support reimbursement. 

RESPONSIBILITIES INCLUDE: 

• Perform retroactive, initial, and concurrent utilization reviews with commercial and third-party payers
• Track authorization dates, concurrent review due dates, and retrospective review deadlines; ensure updates are completed in EMR (e.g., Kipu)
• Provide timely communication and documentation in the event of an insurance denial, paying careful attention to follow utilization review workflows
• Coordinate appeal process with concurrent denials from third party payers within contractual or appropriate time frames, as needed
• Prepare retro authorization and appeal packets or additional documentation requests
• Effectively communicate with multidisciplinary team if there are issues with insurance coverage or authorizations
• Document all payer interactions, determinations, and authorizations in accordance with departmental standards
• Understand and follow all HIPAA and CFR42 requirements
• Participate in departmental continuous quality improvement activities and committees
• Audit caseload daily up to weekly to ensure appropriate insurance, self-pay or out of network information is reflected in each encounter

OTHER DUTIES:   

This job description is intended to provide general guidance and not designed to cover or contain a comprehensive list of relevant activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time, with or without notice.  

ESSENTIAL FUNCTIONS: 

For patient care needs, this is an on-site role. Clearly communicate and exchange information verbally and electronically. Consistent computer and phone, general office equipment use. Generally sedentary, traversing office and facility areas.  

QUALIFICATIONS: 

• Bachelor’s degree in healthcare administration, behavioral health, or a related field required
• Proficiency in EMR systems (e.g., KIPU) and general office software (e.g., Microsoft Office) required
• Minimum of one (1) year of experience working in a behavioral health setting required
• Minimum of one (1) year of experience in healthcare administration, utilization review, admissions, or related insurance-based role preferred
• Knowledge of insurance carriers and third-party administrators and are well versed in the various types of benefit plans (e.g., PPOs, HMOs, EPOs, tribal plans, Single Case Agreements, public insurers, unions, EAPs), preferred