Specialist, Utilization Review

Specialist, Utilization Review

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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.

• Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field preferred
• High School Diploma/GED required
• 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
• Active clinical license (RN, LCSW, LMSW, LPC, LMFT) preferred
• CPR and Handle with Care (HWC) certification required within 30 days of hire
• Knowledge of medical necessity criteria (e.g., Inter Qual, MCG)
• Strong documentation, time management, and communication skills
• Ability to work flexible hours and occasional overtime as needed
• Ability to sit or stand for extended periods, move throughout the facility, 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, meeting deadlines and managing multiple priorities

• Conduct concurrent and retrospective utilization reviews to ensure medical necessity and payer compliance
• Manage pre‑authorizations and continued stay reviews for inpatient and outpatient services
• Communicate clinical information to managed care organizations within required time frames
• Track, document, and enter authorization data accurately into the patient database and UR tracking tools
• Coordinate, schedule, and follow up on peer‑to‑peer reviews with medical providers and payers
• Collaborate with the assessment department to ensure authorization prior to admission
• Assist with discharge reviews, including timely notification and submission of discharge clinical information
• Monitor authorization status to prevent denials and identify trends or barriers impacting length of stay
• Ensure Medicare certification letters are completed and signed by the appropriate provider
• Support UR Manager or Director with reporting, audits, and performance improvement initiatives
• Maintain organized, accurate electronic and paper files in accordance with regulatory standards

• 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

Mid‑Senior level

Full‑time

Other

Hospitals and Health Care