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.

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

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

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

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

• Track caseloads and authorization deadlines; perform follow-ups and escalate unresolved issues.

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

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

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

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

• Review payer correspondence and adverse determinations, ensuring follow-up is completed.

• 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.

• 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 adherence to HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies.

⛳️ 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.

• Ability to interpret clinical documentation and effectively communicate symptoms, functional impairment, risk factors, treatment needs, progress, and discharge barriers.

• Capability 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 strong commitment to patient confidentiality.

• Knowledge of HIPAA and 42 CFR Part 2 requirements is necessary.

• A bachelor's degree in a related healthcare discipline is preferred.

• Familiarity with 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.

• Background 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 better rates, improved co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options 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 managed through Voya.

• Generous PTO – A comprehensive paid time-off policy.

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

• Great Place to Work® Certification.

• A supportive and rewarding workplace.