Utilization Review Specialist

Job not on LinkedIn

🔥 0 minutes ago

🏈 Alabama – Remote

🏈 Alabama – Remote

💵 $60k - $70k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Lakeview Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2001

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Lakeview Health is a nationally recognized evidence-based addiction treatment and rehab program located in Florida. They provide comprehensive treatment options for various substance use disorders, including alcohol and opioid addiction, through gender-responsive programs tailored for men and women. Their expert team of clinicians offers multiple therapeutic approaches, such as cognitive-behavior therapy and dual diagnosis treatment, to support patients in their recovery journey.

📋 Description

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with 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 clinical information supporting medical necessity and requested levels of care • Present clinical information clearly and persuasively to payer representatives using applicable medical-necessity criteria and payer guidelines • Maintain authorization records in electronic medical records, payer portals, tracking systems, and other applications • Monitor caseloads and authorization deadlines; complete follow-up and escalate unresolved barriers • Identify clinical 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 cases 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 as assigned in support of 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 clearly communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge • Ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation • 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 • Bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or a related healthcare discipline preferred • Minimum 1 year of direct utilization review, concurrent review, or payer authorization experience within behavioral health or substance use disorder treatment preferred • Knowledge of ASAM Criteria and experience with residential, inpatient, partial hospitalization, intensive outpatient, and outpatient levels of care preferred • Experience working 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 an equivalent credential, preferred but not required • Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications preferred

🏖️ 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

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume