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Insurance Utilization Reviewer Jobs in Utah (NOW HIRING)

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Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.
What are popular job titles related to Insurance Utilization Reviewer jobs in Utah? For Insurance Utilization Reviewer jobs in Utah, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Utah look for? The top searched job categories for Insurance Utilization Reviewer jobs in Utah are:
Insurance Utilization Reviewer jobs near you

Behavioral Health Utilization/Authorization Specialist

Threshold Billing Solutions

Sandy, UT

$47K - $57K/yr

Full-time

Re-posted 27 days ago

Job description

Description

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Posting
We are seeking a Behavioral Health Utilization Review / Authorization Specialist to support clinical authorization and utilization management for substance use disorder and mental health treatment programs. This role works closely with insurance companies and treatment providers to obtain authorizations for ASAM levels of care, including detoxification, residential, PHP, IOP and GOP treatment services.
Position Summary
The Utilization/Authorization Specialist plays a key role in advocating for clients by obtaining treatment authorizations and facilitating communication between providers and insurance payers. This position is responsible for reviewing behavioral health clinical documentation, submitting authorization requests, and ensuring accurate, timely tracking of coverage. The ideal candidate will be detail-oriented, organized, capable of communicating clearly with both internal teams and external insurance representatives, and may have direct clinical experience working as a Peer Support Specialist, Case Manager, SUDC, LCSW/CSW, CMHC in the substance abuse or mental health treatment field.
Experience in Utilization Review Not Required
While prior utilization review experience is always valued, many of our most successful team members have come from a variety of backgrounds within the behavioral health treatment field. Candidates who have worked in residential treatment centers, outpatient programs, or other clinical/administrative behavioral health settings often transition very well into this role. Their firsthand understanding of the treatment process, client needs, and clinical workflows provides an excellent foundation for learning utilization review.
We provide comprehensive training and ongoing support, so if you bring a strong work ethic, attention to detail, and a passion for supporting access to care, you can thrive with us even without previous UR experience.
Key Responsibilities
  • Maintain proactive and effective communication with insurance payers and managed care organizations.
  • Review and interpret clinical documentation, case notes, and assessments to determine and advocate for the appropriate level of care.
  • Prepare and submit initial and concurrent authorization requests, as well as appeals when necessary.
  • Enter and update authorization details in internal data systems accurately and promptly.
  • Track ongoing authorization needs across all levels of care (RTC, PHP, IOP, OP).
  • Communicate with facility staff and internal departments regarding client coverage and clinical needs.
  • Serve as a client advocate, ensuring access to appropriate care through effective payer communication.
  • Ensure timely documentation of all authorizations, decisions, and payer communications.
  • Perform other related duties as assigned.
Qualifications
  • May have direct clinical/behavioral health experience working as a Peer Support Specialist, Case Manager, SUDC, LCSW/CSW, CMHC in the substance abuse or mental health treatment field is preferred (but not required).
  • Experience in behavioral health or utilization review preferred (but not required).
  • Knowledge of CPT/ICD-10 coding, ASAM/LOCUS criteria, and EMR systems is a plus but not a requirement.
  • Strong verbal and written communication skills.
  • Excellent organization and attention to detail; able to manage multiple tasks and priorities.
  • Critical thinking and analytical skills with the ability to interpret and present clinical information.
  • Ability to work independently and as part of a collaborative team.
  • Proficiency in Microsoft Office and Google Workspace.
  • Comfortable working in a fast-paced environment with deadlines and competing priorities.
Education & Experience
  • High school diploma or equivalent required. Associate’s degree or higher preferred.
  • At least 1 year of experience in behavioral health or utilization review preferred (not required).
  • Prior experience in the substance use and/or mental health treatment field is highly valued.
  • Licensed or credentialed as a Peer Support Specialist, Case Manager, SUDC, LCSW/CSW, CMHC in the substance abuse or mental health treatment field is preferred (but not required).
Benefits
  • Health, dental, and vision insurance
  • Paid time off (PTO)
  • Sick Time
  • Life insurance
  • Short- and long-term disability coverage
  • Lunch catered two times per week
  • Supportive, team-oriented work environment
Work Environment

  • This is a full-time, on-site position located at our Sandy, Utah office.
To Apply: Please submit your resume and a brief cover letter detailing your interest in the role and relevant experience.

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