Utilization Review Coordinator

Position Summary

The Manager of Utilization Review at Arista Recovery provides leadership and oversight of the Utilization Review department within a substance use disorder (SUD) treatment organization. This position is responsible for ensuring that clinical services meet medical necessity criteria, align with payer requirements, and support appropriate reimbursement. The Manager works closely with executive leadership, clinical teams, and external stakeholders to drive operational efficiency, maximize insurance authorizations, and minimize denials across all levels of care.

Key Responsibilities

Leadership & Strategy

• Develop and execute the overall utilization review strategy in alignment with organizational goals.
• Lead, mentor, and manage a UR team.
• Serve as a liaison between the UR department and executive leadership, providing updates, insights, and performance reports.
• Identify trends, risks, and opportunities through data analysis and recommend process improvements.

Clinical Review & Compliance

• Oversee the submission of timely and accurate utilization review documentation for all levels of care (e.g., detox, residential, PHP, IOP).
• Ensure all reviews meet payer-specific criteria (ASAM, DSM-5, MCG, InterQual) and reflect medical necessity.
• Guide the development and implementation of documentation standards to support clinical and financial outcomes.
• Stay current with evolving regulations and payer policies to ensure full compliance.

Insurance & Reimbursement Coordination

• Build and maintain strong relationships with insurance companies, utilization management departments, and care managers.
• Manage the appeals process for denied claims and develop strategies to reduce denial rates.
• Collaborate with the revenue cycle and billing departments to ensure smooth reimbursement workflows and minimize delays.

Training & Development

• Design and implement training programs for UR staff and clinical teams on medical necessity documentation, payer expectations, and industry best practices.
• Foster a culture of accountability, continuous improvement, and cross-departmental collaboration.

Quality & Reporting

• Monitor and analyze key performance indicators (KPIs), including authorization rates, denial trends, appeal success rates, and average length of stay.
• Participate in accreditation readiness (e.g., Joint Commission, CARF) and internal/external audits.

Qualifications

Required:

• Bachelor’s degree in Nursing, Healthcare Administration, Social Work, or related field (Master’s preferred).
• Minimum of 3-5 years of utilization review experience in behavioral health or SUD treatment, including at least 2 year in a leadership role.
• In-depth knowledge of ASAM criteria, DSM-5, payer guidelines, and medical necessity principles.
• Strong understanding of managed care, commercial insurance, Medicaid, and reimbursement processes.
• Proven leadership, team-building, and staff development skills.
• Excellent communication, negotiation, and problem-solving abilities.

Preferred:

• Active clinical license (e.g., RN, LCSW, LMFT, LPC).
• Experience working in Joint Commission- or CARF-accredited facilities.
• Proficiency in EHR and UR management systems.

Work Environment & Physical Requirements

• Primarily office-based or remote; occasional travel to treatment facilities or industry conferences.
• Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment.