Utilization Review Specialist

Position: Utilization Review Specialist

Job Summary: The Utilization Review (UR) Specialist is responsible for ensuring that clients receiving substance use disorder (SUD) treatment services meet clinical criteria for admission, continued stay, and discharge. This role supports compliance with payer requirements, maintains proper documentation, and collaborates with clinical and administrative teams to maximize reimbursement while ensuring high-quality, medically necessary care.

Reports to: VP of Revenue Cycle Management

Duties and Responsibilities:

Duties include, but are not limited to:

• Conduct initial and concurrent reviews to determine medical necessity using established criteria
• Submit authorization requests and clinical documentation to insurance providers in a timely manner
• Monitor authorizations and ensure services rendered align with approved levels of care
• Track and manage authorization expirations and initiate reauthorization requests as needed
• Review clinical records for completeness, accuracy, and compliance with payer and regulatory standards
• Ensure treatment plans, progress notes, and discharge summaries support medical necessity
• Provide feedback to clinical staff to improve documentation quality
• Maintain adherence to HIPAA and confidentiality regulations
• Serve as the primary liaison between the organization and insurance companies for utilization review matters
• Participate in peer-to-peer reviews when required
• Address denials by gathering supporting documentation and submitting appeals
• Stay current with payer guidelines and regulatory changes affecting SUD services
• Collaborate with clinical, admissions, billing, and case management teams to ensure continuity of care and proper utilization of services
• Participate in multidisciplinary team meetings to discuss patient progress and level-of-care needs
• Communicate authorization status and payer requirements to relevant staff
• Maintain accurate records of authorizations, denials, and appeals
• Track utilization metrics and identify trends to improve efficiency and reimbursement
• Participate in audits and quality assurance initiatives
• Perform other duties as assigned

Required Experience/Abilities:

• Bachelor’s degree in behavioral health, nursing, social work, or a related field required.
• Knowledge of ASAM Criteria required
• Minimum of 1 year of experience in utilization review, case management, or clinical services within behavioral health or SUD treatment
• Experience working with commercial insurance, Medicaid, and/or Medicare preferred
• Familiarity with electronic health record (EHR) systems
• Must pass BCI check, all Corporate Compliance checks, and employment drug screen

Desired Experience/Abilities:

• Master’s degree or clinical licensure (e.g., LSW, LPC, LCSW, RN) preferred.3 years in a supervisory or management role within a behavioral health setting
• Working knowledge of CPT and ICD-10 coding systems, with relevant certification (e.g., CPC, CCS-P) or equivalent experience
• Understanding of medical necessity criteria, including experience with InterQual and/or Milliman (MCG) guidelines

Location: Columbus, OH