Utilization Review Specialist

This is a fully remote position, open to applicants in Alabama.

📋 Description

• Execute admissions, precertifications, concurrent reviews, continued stays, step-down reviews, and retrospective evaluations in accordance with payer guidelines and departmental protocols.

• Acquire, document, and oversee authorizations throughout the continuum of care.

• Examine medical records and collaborate with treatment teams to gather comprehensive clinical information substantiating medical necessity and requested levels of care.

• Articulate clinical information effectively and convincingly to payer representatives, utilizing medical-necessity criteria and payer directives.

• Maintain authorization records within electronic medical records, payer portals, tracking systems, and various applications.

• Monitor caseloads and authorization deadlines on a daily basis; perform follow-ups and escalate unresolved issues.

• Identify gaps or inconsistencies in clinical documentation and communicate requirements to clinicians, providers, or leadership.

• Coordinate with clinical and case management teams regarding transitions, discharge planning, and changes in levels of care.

• Elevate adverse determinations that necessitate peer-to-peer reviews, reconsiderations, appeals, or leadership intervention.

• Prepare case summaries and supporting documents for peer reviews, appeals, and escalations to payers.

• Review payer correspondence and adverse determinations, communicate outcomes, and carry out follow-ups.

• Engage in denial reviews, root-cause analyses, quality audits, training, and performance improvement initiatives.

• Adhere to utilization review policies, workflows, escalation processes, and documentation standards across assigned facilities and states.

• Stay informed on payer policies, authorization prerequisites, medical necessity criteria, regulatory standards, and service-line requirements.

• Collaborate with Utilization Review leadership, admissions, clinical teams, facility leaders, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners.

• Safeguard patient privacy and ensure adherence to HIPAA, 42 CFR Part 2, payer requisites, accreditation standards, and organizational policies.

• Perform additional duties as assigned to support Utilization Review and Revenue Cycle objectives.

⛳️ Requirements

• High school diploma or equivalent is required.

• At least 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related field.

• Experience in Behavioral Health and/or Substance Use Disorder is mandatory.

• Familiarity with insurance authorization processes, including precertification, concurrent reviews, continued-stay reviews, authorization tracking, and payer follow-ups.

• Ability to interpret clinical documentation and articulate symptoms, functional impairments, risk factors, treatment requirements, progress, and discharge barriers.

• Capability to manage multiple cases, payer deadlines, and competing priorities accurately and with appropriate escalation.

• Excellent verbal and written communication skills, professional judgment, attention to detail, and a strong commitment to patient confidentiality.

• Understanding of HIPAA and 42 CFR Part 2 requirements.

• Relevant college coursework, professional certification, or equivalent directly related experience is highly preferred.

• A Bachelor's degree in a related healthcare field is preferred.

• Knowledge of ASAM Criteria and behavioral health levels of care is preferred.

• Experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers is preferred.

• Experience in preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals is preferred.

• An active clinical license or relevant certification is preferred but not mandatory.

• Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications is preferred.

🏝️ Benefits

• Medical Coverage – Three new BCBSAL medical plans featuring improved rates, enhanced co-pays, and better prescription benefits.

• Expanded Coverage – Options available for domestic partners and a broader network of in-network providers.

• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) that includes digital wellness tools such as Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Options for pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – 401(k) plan managed by Voya.

• Generous PTO – A comprehensive paid time off policy.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more each week.

• Great Place to Work® Certification.

• A supportive and rewarding workplace.