Utilization Review Specialist

🔥 16 minutes ago

🏈 Alabama – Remote

🏈 Alabama – Remote

💵 $60k - $70k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

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Bradford Health Services

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1977

🏥 Healthcare

🧘 Wellness

🤝 Non-profit

Healthcare • Wellness • Non-profit

Bradford Health Services is a leading provider of addiction treatment programs, offering a wide range of services to support individuals in their recovery journey. With facilities across the Southeast, they provide inpatient and outpatient rehabilitation, detox services, and various specialty programs tailored to meet the unique needs of their patients. Their commitment to affordable, evidence-based treatment ensures that individuals can access the support they need to reclaim their lives from addiction.

📋 Description

• Evaluate patient records, treatment plans, and clinical data to determine medical necessity, appropriateness of care, and resource utilization. • Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows. • Obtain, document, and monitor authorizations across the continuum of care. • Review medical records and collaborate with treatment teams to obtain complete, accurate, and timely clinical information. • Present clinical information to payer representatives using medical-necessity criteria and payer guidelines. • Maintain authorization records in electronic medical records, payer portals, tracking systems, and designated applications. • Monitor caseloads and authorization deadlines; follow up and escalate unresolved barriers. • Identify documentation gaps or inconsistencies and communicate needs to clinicians, providers, or leaders. • Coordinate with clinical and case-management teams regarding transitions, discharge planning, and changes in level of care. • Escalate potential adverse determinations requiring peer-to-peer review, reconsideration, appeal, or leadership intervention. • Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations. • Review payer correspondence and adverse determinations, communicate outcomes, and complete follow-up. • Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives. • Follow utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states. • Maintain knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and service-line requirements. • Collaborate with Utilization Review leadership, admissions, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners. • Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies. • Perform other duties supporting Utilization Review and Revenue Cycle objectives.

🎯 Requirements

• High school diploma or equivalent required. • Minimum 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related function. • Behavioral Health and/or Substance Use Disorder experience required. • Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up. • Ability to interpret clinical documentation and communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge. • Ability to manage multiple cases, payer deadlines, and competing priorities. • Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality. • Working knowledge of HIPAA and 42 CFR Part 2 requirements. • Relevant college coursework, professional certification, or equivalent directly related experience strongly preferred. • Preferred: bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or related healthcare discipline. • Preferred: knowledge of ASAM Criteria and residential, inpatient, partial hospitalization, intensive outpatient, and outpatient levels of care. • Preferred: experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers. • Preferred: experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals. • Preferred: active clinical license or relevant certification, such as RN, LPN/LVN, LMSW, LPC, CADC, LADAC, CCM, or equivalent credential. • Preferred: experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications.

🏖️ Benefits

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits. • Expanded Coverage – Options for domestic partners and a wider network of in-network providers. • Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching. • Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more. • Student Loan Repayment – Available for nurses and therapists. • Retirement Benefits – 401(k) plan through Voya. • Generous PTO – A robust paid time off policy. • Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week. • Great Place to Work® Certification and supportive, rewarding workplace.