Utilization Review Specialist
Remote · United States
Job Summary
Utilization Review Specialist responsible for ensuring that SUD treatment services meet clinical criteria for admission, continued stay, and discharge, while complying with payer requirements and maintaining proper documentation. Primary liaison between the organization and insurance companies for authorization matters; conduct initial and concurrent reviews, submit and track authorizations, monitor authorizations and denials, and pursue appeals as needed. Ensures treatment plans, progress notes, and discharge summaries support medical necessity, maintains HIPAA/confidentiality, collaborates with clinical, admissions, billing, and case management teams to maximize reimbursement and ensure continuity of care; participates in audits, quality assurance, and multidisciplinary team discussions; supports knowledge of CPT/ICD-10 coding and payer guidelines.
Required Qualifications
- Bachelor’s degree in behavioral health, nursing, social work, or a related field required.
- Knowledge of ASAM Criteria required
- Minimum of 1 year of experience in utilization review, case management, or clinical services within behavioral health or SUD treatment
- Experience with commercial insurance, Medicaid, and/or Medicare preferred
- Familiarity with electronic health record (EHR) systems
- Must pass BCI check, all Corporate Compliance checks, and employment drug screen
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