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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.