Utilization Review Specialist

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

📋 Description

• Ensure the provision of clinically appropriate care, efficient discharge processes, and cost-effective service utilization across the entire treatment continuum.

• Conduct continuous clinical evaluations of patients from admission to discharge in collaboration with a multidisciplinary team.

• Lead prompt and clinically sound reviews and responses related to admissions, ongoing stays, discharges, and appeals.

• Act as a liaison between payers and clinical care teams.

• Utilize criteria to monitor admissions, levels of care, and ongoing patient stays.

• Communicate with third-party payers for initial and concurrent clinical reviews.

• Review patient records to ensure ongoing medical necessity.

• Document actions taken and information shared with care team members or third-party payers.

• Notify clinical care teams and management when patients no longer fulfill medical necessity criteria.

• Refer cases that exceed expected length of stay, costs, or resource utilization to management.

• Conduct verbal or fax clinical reviews with payers.

• Gather data on length-of-stay variances, lost days, costs, discharge barriers, transitions, and denied days.

• Prepare appeals for denied cases when appropriate.

• Adhere to company policies, confidentiality obligations, and standards of care.

• Perform other job-related tasks as assigned.

⛳️ Requirements

• A Master’s Degree in Social Sciences or relevant experience is required.

• An active substance abuse or mental health license in the state where treatment services are provided is mandatory.

• Must maintain applicable state licensure requirements at the time of hire and throughout the duration of employment.

• At least 1 year of experience in a related field is required.

• Ability to exercise discretion and independent judgment in all aspects of job performance, including maintaining professional boundaries and strict confidentiality regarding client activities and documentation.

• Capable of applying clinical judgment, ethics, and accountability to develop and implement treatment plans and other clinical documentation.

• Strong personal boundaries and the ability to establish rapport with patients and staff are essential.

• Must understand and adhere to the ethical standards set by the respective licensure governing board.

• Exceptional critical thinking abilities.

• Excellent organizational skills.

• Strong communication skills; able to convey information clearly and concisely, both verbally and in writing.

• Quick and effective in identifying and resolving problematic situations.

• Comfortable analyzing information and managing complexity.

• Attention to detail and accuracy is crucial.

• Must be able to handle confidential material reliably.

• Ability to interact and communicate with individuals at all organizational levels.

• Capable of managing multiple tasks simultaneously with professionalism and ease.

• Ability to effectively prioritize workload in a fast-paced environment.

• Proficient with Microsoft Office Suite.

• Employees with potential access to protected health information must comply with all procedures and guidelines governed by HIPAA.

🏝️ Benefits

• Subsidized Health Insurance Coverage for Employee, Spouse, & Dependent(s).

• 100% Employer Paid Basic Life Insurance equal to 1x annual salary, up to $100,000.

• 100% Employer Paid Employee Assistance Program.

• Voluntary Dental, Vision, Short-Term Disability, Supplemental Life & AD&D, Critical Illness, Accident, and Hospital Indemnity Insurance.

• Pre-tax Savings Accounts for all IRS-allowable medical and dependent care expenses.

• Generous Paid Time Off plan.

• Employee Referral Bonuses.

• 401K Retirement Plan & Employer Match.