Position Aetna Utilization Review Jobs (NOW HIRING)

Description
DEFINITION:
The Utilization Review Specialist is responsible for assessing and submitting clinical documentation to ensure that services provided meet medical necessity, payer requirements, and organizational standards. This role serves as a liaison between clinical staff and insurance companies, coordinating timely authorizations and communicating utilization decisions. The Utilization Review Specialist supports quality care by ensuring appropriate service delivery and promoting effective use of resources.
This position will report directly to the Finance Department under the designated supervisor for utilization functions. Until a Utilization Review Manager is hired, oversight and support will be provided by the Revenue Cycle Project Analyst. This role will also work in close collaboration with the Addiction Recovery Center (ARC) Director and/or County Operational Director to ensure clinical alignment and support service delivery.
EDUCATION AND EXPERIENCE:
An associate's degree or higher in a healthcare-related field is preferred but not required and may be substituted with relevant field experience.
At least one year of experience in behavioral health, healthcare administration, utilization review, or case management. Prior experience working directly with individuals with serious mental illness, substance use disorders, or co-occurring conditions is highly valued. Familiarity with payer systems, clinical documentation, and authorization procedures is strongly encouraged.
A solid understanding of medical necessity criteria such as InterQual, ASAM, Availity, or LOCUS will be beneficial in this role.
KNOWLEDGE AND SKILLS:
Strong understanding of behavioral health and/or medical terminology and treatment modalities
Working knowledge of payer authorization processes and documentation standards
Ability to apply medical necessity criteria and interpret clinical documentation accurately
Strong written and verbal communication skills
High level of attention to detail and organizational skills
Proficiency in electronic health record (EHR) systems and Microsoft Office Suite
Ability to work both independently and collaboratively in a fast-paced environment
Knowledge of HIPAA regulations and confidentiality requirements
JOB DUTIES AND RESPONSIBILITIES:
Responsible to and immediately supervised by the Revenue Cycle Project Analyst with direct communication and training with ARC Director and County Operational Director.
This position is responsible and held accountable for the following duties:
• Review clinical documentation for accuracy and completeness to support medical necessity
• Apply appropriate review criteria (e.g., InterQual, ASAM, Availity) to determine level of care and authorization requirements
• Submit timely prior authorization and continued stay requests to payers
• Follow up with insurance companies to obtain authorization determinations and resolve delays
• Communicate outcomes and required next steps to clinical staff and document updates in the EHR
• Monitor expiring authorizations and ensure continued stay reviews are completed on time
• Assist in resolving denials or discrepancies by scheduling and participating in peer to peers as well as submitting appeals or additional information as needed
• Track and report on authorization trends, outcomes, and barriers to care
• Monitor faxes to ensure proper response times are met and calls are returned
• Upload faxes as well as log communications into the EHR
• Reporting denials to ARC Director/County OD to ensure immediate adjustment of treatment plan and discharge plan
• Maintain current knowledge of payer guidelines, review criteria, and organizational policies
• Participate in internal trainings, audits, and quality improvement initiatives as assigned as well as Availity and MCO trainings
• Perform other reasonably related duties as assigned by the ARC Director/County OD or Executive Team members as requested.
• Must be willing and able to perform all job-related travel normally associated with this position.
• Regular and predictable attendance is an essential job requirement.
• Must meet "satisfactory" expectations at any scheduled job performance evaluation. Quality of work will be evaluated through training, skill, or special purpose. Must be competent and adequate.
Must perform the specific job duties listed above to meet position expectations.
In addition, must possess skill in working cooperatively and effectively with clients, staff, management, and other professional groups; in exercising mature judgment in dealing with people; in presenting ideas clearly and accurately; in reading and comprehending the English language; and in communicating effectively, both orally and in writing.