Job Type: Full-Time
Department: Clinical Operations / Utilization Management
Reports To: Utilization Review Manager
Position Summary:
We are seeking a detail-oriented and highly organized Utilization Review (UR) Specialist to join our Behavioral Health team. The ideal candidate will be responsible for supporting clinical decision-making and utilization management processes through meticulous data entry, documentation review, and coordination with internal and external stakeholders. This role plays a vital part in ensuring timely and accurate authorization and review of behavioral health services while maintaining compliance with payer and regulatory requirements.
Key Responsibilities:
1. Utilization Review CoordinationReview patient clinical documentation to determine medical necessity for behavioral health services.
Collaborate with clinicians to gather additional information when required.
Submit timely authorization requests to insurance companies or third-party administrators.
Accurately enter clinical data, patient information, and authorization outcomes into electronic health records (EHR) and UR tracking systems.
Maintain up-to-date logs of all utilization review activities, including approval/denial status, payer communications, and relevant deadlines.
Perform quality checks to ensure data accuracy, completeness, and compliance with organizational standards.
Interface with insurance providers to verify benefits, submit clinical reviews, and follow up on authorizations.
Ensure compliance with HIPAA, state, and federal regulations governing behavioral health and UR processes.
Assist in generating weekly and monthly reports related to authorization volumes, turnaround times, and denial trends.
Support audit requests by compiling required documentation and logs.
Required Qualifications:
High School Diploma or GED required; Associate’s or Bachelor’s degree in Psychology, Health Sciences, or related field preferred.
1–2 years of experience in utilization review, medical billing, insurance authorization, or behavioral health services.
Proficient in data entry with strong attention to detail (minimum 50 WPM preferred).
Experience working with EHR systems (e.g., CareLogic, Credible, Epic, etc.).
Knowledge of insurance processes, including Medicaid, Medicare, and commercial payers.
Strong organizational and time management skills with the ability to manage multiple priorities.
Preferred Skills & Competencies:
Familiarity with DSM-5 diagnostic criteria and behavioral health terminology.
Ability to read and understand clinical documentation such as treatment plans and progress notes.
Proficient in Microsoft Office Suite (Excel, Word, Outlook).
Team-oriented mindset with effective written and verbal communication skills.
Capable of working in a fast-paced, deadline-driven environment.
Work Environment:
Standard office setting or remote work, depending on location.
Regular use of computer and telephone systems.
May require flexible scheduling to meet urgent utilization review timelines.
Why Join Us?
Meaningful work that directly impacts client care and outcomes.
A supportive team culture with opportunities for growth and development.
Competitive compensation and benefits package.