Utilization Review Specialist

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

📋 Description

• Conduct admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with payer specifications and departmental processes.

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

• Analyze medical records and collaborate with treatment teams to gather timely clinical information that substantiates medical necessity and appropriate level of care.

• Present clinical information to payer representatives utilizing medical necessity criteria and payer guidelines.

• Keep precise authorization records in electronic medical records, payer portals, tracking systems, and other applications.

• Monitor caseloads and authorization timeframes; perform follow-ups and escalate unresolved issues.

• Identify gaps or discrepancies 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 level of care.

• Escalate adverse determinations that require peer-to-peer review, reconsideration, appeal, or leadership intervention.

• Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations.

• Review payer correspondence and adverse determinations; communicate results and ensure follow-up is completed.

• 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 about payer policies, authorization requirements, medical necessity criteria, regulatory standards, and service line specifications.

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

• Safeguard patient privacy and adhere to HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies.

• Perform additional duties that support Utilization Review and Revenue Cycle objectives.

⛳️ Requirements

• A 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 essential.

• Proficient understanding of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up.

• Capability to interpret clinical documentation and convey symptoms, functional impairments, risk factors, treatment needs, progress, and discharge barriers.

• Ability to manage multiple cases, payer deadlines, and competing priorities with precision and appropriate escalation.

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

• Familiarity with HIPAA and 42 CFR Part 2 requirements.

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

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

• Knowledge of ASAM Criteria and behavioral healthcare 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.

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

🏝️ Benefits

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

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

• Mental Health Support – Enhanced 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 through 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 per week.

• Great Place to Work Certification.

• Supportive and rewarding workplace.