Utilization Review Specialist

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

📋 Description

• Assess patient records, treatment plans, and clinical data to evaluate medical necessity, appropriateness of care, and resource utilization.

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

• Acquire, document, and track authorizations throughout the care continuum.

• Analyze medical records and collaborate with treatment teams to gather complete, accurate, and timely clinical information.

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

• Maintain authorization records in electronic medical records, payer portals, tracking systems, and designated applications.

• Monitor caseloads and authorization deadlines; follow up and escalate any unresolved issues.

• Identify documentation gaps or inconsistencies and communicate requirements to clinicians, providers, or leaders.

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

• Escalate potential adverse determinations that need 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 outcomes, and perform necessary follow-up.

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

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

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

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

• Safeguard patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies.

• Execute other duties that support Utilization Review and Revenue Cycle goals.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• 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.

• Familiarity with 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 impairment, risk factors, treatment needs, progress, and barriers to discharge.

• Proficient in managing multiple cases, payer deadlines, and competing priorities.

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

• Working knowledge of HIPAA and 42 CFR Part 2 requirements.

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

• Preferred: bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or a related healthcare field.

• Preferred: familiarity with ASAM Criteria and various levels of care such as residential, inpatient, partial hospitalization, intensive outpatient, and outpatient.

• Preferred: experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers.

• Preferred: experience in preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals.

• Preferred: active clinical license or relevant certification, such as RN, LPN/LVN, LMSW, LPC, CADC, LADAC, CCM, or equivalent credential.

• Preferred: experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications.

🏝️ Benefits

• Medical Coverage – Three new BCBSAL medical plans offering 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) featuring digital wellness tools like 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 each week.

• Recognized as a Great Place to Work® with a supportive and rewarding workplace environment.