Utilization Review

Position Summary

The Utilization Review (UR) Specialist is responsible for obtaining and maintaining insurance authorizations for clients receiving substance use disorder treatment services. This position works closely with clinical staff, admissions, and insurance companies to ensure medical necessity documentation is accurate, authorizations are obtained timely, and reimbursement is maximized while maintaining compliance with payer requirements, Medicaid regulations, and accreditation standards.

Essential Duties and Responsibilities

• Obtain initial and concurrent insurance authorizations for all levels of care.
• Review clinical documentation to ensure it supports medical necessity.
• Submit clinical information to insurance companies within required timeframes.
• Monitor authorization expiration dates and request extensions before expiration.
• Communicate authorization decisions and payer requirements to clinical staff.
• Track approved days and notify leadership of denials or reductions in care.
• Prepare and submit appeals for denied services when appropriate.
• Maintain accurate authorization records in the electronic health record (EHR).
• Work collaboratively with Admissions, Clinical, Nursing, and Billing departments.
• Verify insurance benefits and coverage when necessary.
• Monitor payer portals for authorization updates.
• Assist with Medicaid and managed care authorization processes.
• Participate in utilization review meetings and case conferences.
• Generate reports on authorization status, denials, appeals, and payer trends.
• Ensure compliance with Joint Commission, state, federal, and payer regulations.
• Maintain confidentiality in accordance with HIPAA regulations.
• Perform other duties as assigned.

Qualifications

• High school diploma required; Associate's or Bachelor's degree preferred.
• Minimum of two years of utilization review, case management, medical billing, or behavioral healthcare experience preferred.
• Experience in substance use disorder or behavioral health treatment strongly preferred.
• Knowledge of ASAM Criteria preferred.
• Familiarity with Medicaid, commercial insurance, and managed care plans.
• Strong organizational and time management skills.
• Excellent verbal and written communication skills.
• Ability to prioritize multiple cases in a fast-paced environment.
• Proficient in Microsoft Office and electronic health record systems.

Knowledge, Skills, and Abilities

• Understanding of insurance authorization processes.
• Knowledge of medical necessity criteria and documentation standards.
• Strong analytical and critical thinking skills.
• Excellent customer service and professional communication.
• Ability to work independently while collaborating with interdisciplinary teams.
• Attention to detail and accuracy.
• Ability to maintain confidentiality.

Performance Expectations

• Maintain timely insurance authorizations with minimal lapses.
• Reduce avoidable authorization denials.
• Ensure documentation meets payer standards.
• Maintain accurate records and reporting.
• Demonstrate professionalism, teamwork, and excellent customer service.
• Comply with all organizational policies, HIPAA, Joint Commission standards, and applicable federal and New Jersey regulations.