Utilization Review Rn Jobs in Pittsburgh, PA (NOW HIRING)

Gateway Rehab Center (GRC) is hiring a full-time Utilization Review Liaison! In this important administrative and clinical support role, you will help ensure patients receive the appropriate level of care by coordinating authorizations, conducting utilization reviews, and collaborating with clinical teams and insurance providers to support treatment coverage and reimbursement. This position is fully remote and offers the opportunity to make a meaningful impact on patient access to care from your home office. To be considered for the position, you must live within the Pittsburgh, PA area or surrounding counties.

If you're detail-oriented, organized, and enjoy working at the intersection of patient care, insurance, and healthcare operations, keep reading!

Why You'll Love Working at GRC

• Mission-driven work supporting individuals and families impacted by addiction.
• Opportunity to play a vital role in ensuring access to treatment services.
• Collaborative environment working alongside clinical, admissions, and billing teams.
• Meaningful work that helps patients receive the care they need throughout their recovery journey.
• Comprehensive benefits package, including contribution toward the medical insurance plan of your choice: Highmark or UPMC, plus access to employee discount programs and additional supportive benefits!

Why This Role is Important to SUD Treatment

GRC's Utilization Review team is changing lives, and as a Utilization Review Liaison, you'll be at the forefront of this effort. By securing and maintaining treatment authorizations, monitoring coverage, and advocating for continued care when needed, you help remove barriers to treatment and ensure patients have access to critical recovery services. Your work directly supports quality patient care, treatment continuity, and organizational success. This is more than an administrative role. It's an opportunity to make a lasting impact on recovery every day.

Responsibilities:

• Gather clinical information needed for concurrent and retrospective reviews.
• Complete concurrent and retrospective review processes with payors for treatment authorization.
• Collaborate with utilization review team members and clinical staff to prepare for reviews and maintain daily workflow.
• Enter authorization information into the patient database.
• Communicate authorization status updates to clinical staff.
• Monitor patients' last covered day of treatment and notify appropriate staff of upcoming coverage expirations.
• Investigate and resolve issues involving incomplete or missing authorizations.
• Identify errors that could negatively impact reimbursement for patient treatment.
• Collaborate with multiple departments to ensure continuity of treatment coverage.
• Educate clinical and support staff regarding county-funded, managed care, and commercial insurance procedures.
• Complete peer-to-peer reviews as needed.
• Communicate discharge information to funding sources when required.
• Coordinate with clinical teams to ensure funding sources are notified of patient status changes.
• Investigate denied claims and assist in efforts to recover payment for services rendered.
• Attend managed care provider meetings as needed.
• Participate in required GRC trainings and in-service programs.

What You Bring

• Strong understanding of utilization review, insurance authorization processes, and managed care practices.
• Excellent verbal and written communication skills.
• Strong organizational skills and attention to detail.
• Ability to manage multiple priorities in a fast-paced environment.
• General understanding of ASAM Criteria.
• Familiarity with substance use disorder, mental health, and behavioral healthcare treatment services.
• Strong problem-solving and critical-thinking abilities.
• Proficiency in Microsoft Office applications, including Word, Excel, and email systems

What Do We Require?

• Bachelor's degree.
• Familiarity with drug and alcohol treatment, mental health treatment, and/or managed care processes.
• Proficiency with computer systems and Microsoft Office applications.

Preferred Qualifications

• Master's degree.
• Registered Nurse (RN) with current Pennsylvania licensure.
• Previous experience with utilization review, managed care, insurance authorizations, or healthcare reimbursement processes.

Additional Requirements

• Pass a PA Criminal Background Check.
• Obtain PA Child Abuse and FBI Fingerprinting Clearances.
• Pass a Drug Screen.
• Complete a 2-Step TB Test.

What Are the Work Conditions?

• Remote.
• Prolonged periods of sitting and working on a computer.
• Minimal physical demands.
• Significant attention to detail required.
• Mental demands include problem-solving complex coverage issues, analyzing authorization requirements, and coordinating information across multiple departments.

GRC is an Equal Opportunity Employer committed to diversity, equity, inclusion, and belonging. We value diverse voices and lived experiences that strengthen our mission and impact.