Utilization Review Specialist
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Job Description
Utilization Review Specialist managing behavioral-health authorizations and medical-necessity reviews. Supporting Bradford Health Services’ addiction-treatment network, payer approvals, and patient-care continuity.
Responsibilities:
- Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows
- Obtain, document, and monitor authorizations across the continuum of care
- Review medical records and collaborate with treatment teams to obtain complete clinical information supporting medical necessity and requested levels of care
- Present clinical information clearly and persuasively to payer representatives using medical-necessity criteria and payer guidelines
- Maintain authorization records in electronic medical records, payer portals, tracking systems, and other applications
- Monitor caseloads and authorization deadlines daily; complete follow-up and escalate unresolved barriers
- Identify clinical documentation gaps or inconsistencies and communicate needs to clinicians, providers, or leaders
- Coordinate with clinical and case-management teams on transitions, discharge planning, and level-of-care changes
- Escalate adverse determinations requiring 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 complete follow-up
- Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives
- Follow utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states
- Maintain knowledge of 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
- Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies
- Perform other duties as assigned in support of Utilization Review and Revenue Cycle objectives
Requirements:
- High school diploma or equivalent required
- Minimum 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 function
- Behavioral Health and/or Substance Use Disorder experience required
- Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up
- Ability to interpret clinical documentation and communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge
- Ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation
- Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality
- Working knowledge of HIPAA and 42 CFR Part 2 requirements
- Relevant college coursework, professional certification, or equivalent directly related experience strongly preferred
- Bachelor's degree in a related healthcare discipline preferred
- Knowledge of ASAM Criteria and behavioral health levels of care preferred
- Experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers preferred
- Experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals preferred
- Active clinical license or relevant certification preferred but not required
- Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications preferred
Benefits:
- Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits
- Expanded Coverage – Options for domestic partners and a wider network of in-network providers
- Mental Health Support – Improved 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 – 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 robust 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
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