Utilization Review (UR) Specialist

• Obtain initial authorizations for treatment episodes across all levels of care (PHP, IOP, SUD OP, TBS/PSR, Med Management).
• Complete continued stay reviews (CSRs) and reauthorization requests by the required deadlines.
• Submit Medicaid prior authorization (PA) packets including clinical documentation, notes, assessments, and treatment plans.
• Monitor authorization status in payer portals and maintain communication with Medicaid MCOs (CareSource, Buckeye, Molina, Paramount, UHC, AmeriHealth, etc.).

• Review clinical documentation to ensure it meets medical necessity standards required by ODM (Ohio Department of Medicaid) and payer guidelines.
• Verify that progress notes, assessments, treatment plans, and signatures are complete, accurate, and compliant.
• Assist clinicians in identifying documentation gaps or areas needing clarification for successful authorization.
• Ensure timely collection of required documents, including:
  • Comprehensive assessments
  • ASAM Level of Care justifications
  • Treatment plans
  • Progress notes
  • Urine drug screens
  • Psychiatric evaluations
  • Discharge summaries

• Communicate with Clinical Director and therapists regarding upcoming authorization deadlines, missing documentation, and required updates.
• Collaborate with billing to ensure authorized units match billed services and resolve discrepancies.
• Maintain an organized authorization tracker with start dates, end dates, units, and approvals.
• Respond promptly to payer inquiries and clinical review requests.

• Maintain compliance with Medicaid, ODM, CARF/Joint Commission, OhioMHAS, and payer utilization management policies.
• Ensure documentation standards meet payer audits and state regulatory requirements.
• Follow up on denials and submit appeals with corrected documentation when appropriate.

• Minimum 2 years’ experience in Utilization Review, Medicaid authorization, Behavioral Health Billing, Case Management, or similar role.
• Strong knowledge of Medicaid MCO authorization portals and processes.
• Familiarity with medical necessity documentation for behavioral health/SUD.
• Understanding of ASAM Criteria and justification for levels of care.
• Ability to read and interpret clinical notes and assessments.
• Strong communication and coordination skills between clinical and billing departments.
• High attention to detail and ability to meet strict deadlines.

• Experience in a Substance Use Disorder or Mental Health treatment center.
• Knowledge of Alleva EMR or similar EMR platforms.
• CDCA, QMHS, LSW, or similar credential (not required but beneficial).

• Maintain >95% authorization retention rate for all active clients.
• Submit all prior authorizations and continued stay reviews before expiration.
• Zero preventable authorization lapses due to missing documentation.
• Maintain accurate and up-to-date authorization logs and communication records.

• Fast-paced behavioral health environment.
• Remote flexibility depending on needs of department.
• Requires effective communication with clinical providers and payer representatives.

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