Specialist, Utilization Review

Position Summary

The Utilization Review Specialist is responsible for managing and coordinating the utilization review process for inpatient and outpatient behavioral health services. This role ensures medical necessity, timely authorizations, regulatory compliance, and effective communication with managed care organizations. The Specialist works collaboratively with clinical teams, the assessment department, and leadership to support appropriate level-of-care decisions, optimize reimbursement, and reduce denials. This position requires a minimum of three years of utilization review experience within a behavioral health hospital setting.

Qualifications

Education:

• Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field preferred
• High School Diploma/GED required

Experience:

• Minimum of 3 years of utilization review experience in a behavioral health hospital (inpatient and/or outpatient)
• Demonstrated experience with managed care authorizations, concurrent reviews, and payer communication

Licensure/Certification:

• Active clinical license (RN, LCSW, LMSW, LPC, LMFT) preferred
• CPR and Handle with Care (HWC) certification required within 30 days of hire

Additional Requirements:

• Knowledge of medical necessity criteria (e.g., InterQual, MCG)
• Strong documentation, time management, and communication skills
• Ability to work flexible hours and occasional overtime as needed

Key Responsibilities

• Conducts concurrent and retrospective utilization reviews to ensure medical necessity and payer compliance
• Manages pre-authorizations and continued stay reviews for inpatient and outpatient services
• Communicates clinical information to managed care organizations within required timeframes
• Tracks, documents, and enters authorization data accurately into the patient database and UR tracking tools
• Coordinates, schedules, and follows up on peer-to-peer reviews with medical providers and payers
• Collaborates with the assessment department to ensure authorization prior to admission
• Assists with discharge reviews, including timely notification and submission of discharge clinical information
• Monitors authorization status to prevent denials and identifies trends or barriers impacting length of stay
• Ensures Medicare certification letters are completed and signed by the appropriate provider
• Supports UR Manager or Director with reporting, audits, and performance improvement initiatives
• Maintains organized, accurate electronic and paper files in accordance with regulatory standards

Physical, Mental, and Special Demands

• Ability to sit or stand for extended periods and move throughout the facility as needed
• Ability to bend, reach, stoop, and perform light lifting
• Visual and cognitive ability to review clinical documentation, payer guidelines, and electronic health records
• Ability to work efficiently in a fast-paced healthcare environment with frequent interruptions
• Ability to meet deadlines, manage multiple priorities, and perform repetitive data-related tasks