Utilization Review Specialist

Description

 The Utilization Review Specialist coordinates insurance authorizations for individual therapy and IOP  services, ensuring clients receive appropriate and timely care. This role works closely with clinical staff,  psychiatry, and payors to gather documentation, review medical necessity, and support treatment  planning. Strong communication, attention to detail, and knowledge of behavioral health services are  essential. The specialist plays a key role in supporting client recovery and care continuity within the  Emotional Wellness & Recovery team.  

Requirements

 This position description should not be interpreted as all inclusive, it may be updated as funding  deliverables, clinical/agency guidelines, and CDC guidelines change.  It is intended to identify the major  responsibilities and requirements of this position.  The incumbents may be requested to perform job related responsibilities and tasks other than those stated in this position description.  Essential Duties, Tasks, and Responsibilities:  • Serve as liaison between managed care organizations (MCOs) and clinical staff to ensure timely  authorizations for mental health and substance use services.  • Conduct pre-certification, concurrent, discharge, and retrospective reviews; initiate appeals and  peer reviews as needed.  • Monitor patient length of stay and communicate updates or issues to clinical and medical staff  to support appropriate care planning.  • Ensure accurate and timely documentation of all utilization reviews, determinations, and  communications in the electronic medical record (EMR) system.  • Maintain current knowledge of payer requirements and apply clinical review criteria to  determine medical necessity and service appropriateness.  • Collaborate with the billing team to ensure alignment between clinical documentation and  reimbursement processes.  • Participate in regular audits of client charts and documentation, including monthly spot checks,  to ensure compliance with payer and agency standards.  • Support Quality Management efforts by participating in chart audits, data collection, and  performance improvement reviews.  • Assist with enrolling clients in Patient Assistance Programs (PAPs) to support access to  medications and services.  • Assist in staff training and education related to documentation standards, continued stay  criteria, and medical necessity guidelines.  • Work as part of a multidisciplinary team to support care coordination and ensure efficient, high quality service delivery.  • Collaborate with Quality Management and department leadership to report on utilization  trends, denials, appeals, and service quality metrics.  • Initiate and manage appeals for denied services, including coordinating peer review calls and  submitting required documentation.  • Perform other duties as assigned to support department operations and quality care delivery. 

 MINIMUM QUALIFICATIONS & EXPERIENCE :  • Minimum of 2 years’ experience in behavioral health, substance use treatment, or related  clinical setting.  • Previous experience in utilization review, insurance authorization, or care management strongly  preferred.  • Demonstrated ability to interpret and apply ASAM criteria to clinical documentation.  • Experience working with insurance payers and understanding of medical necessity  requirements.  • Familiarity with ICD-10 codes and behavioral health diagnosis documentation.  • Proven ability to collaborate within a multidisciplinary team, including clinical and administrative  staff.  • Experience conducting chart audits and participating in quality management or compliance  reviews.  • Proficiency in electronic medical record (EMR) systems and accurate, timely documentation.  •   Strong problem-solving skills and the ability to manage multiple priorities in a fast-paced  environment. 

 PREFERRED KNOWLEDGE, SKILLS, ABILITIES & OTHER APTITUDES (KSAOs):  Knowledge, Skills, Abilities, and Other Aptitudes (KSAOs): 

 LICENSE/LICENSURE:  • LSCW, LMHC or LMFT LMHC, or RN highly desired 

 TRAVEL:   • Local travel between PIHC sites and to and from community agencies will be required.  • Occasional travel to events for training and promotion of salient services to AIDS Service  Organizations.  Occasional evening and weekend work is required and working greater  than 40 hours per week may be required.

  PHYSICAL DEMANDS  • The physical demands described here are representative of those that must be met by  an employee to successfully perform the essential functions of this job.  Reasonable  accommodation may be made to enable individuals with disabilities to perform the  essential functions.    • While performing the duties of this job, the employee is frequently required to sit and  talk or hear.  The employee is occasionally required to walk, use hands to finger, handle,  or operate computers, objects, tools, or controls and reach with hands and arms.  • The employee must occasionally lift and/or move up to 40 pounds.  Specific vision  abilities required by this role include close vision and the ability to adjust focus.