Utilization Review Specialist
23 days ago
Englewood Cliffs
Job Description What you will be doing? The Utilization Review (UR) Specialist is a critical member of the administrative team at Advanced Revenue Solutions and is responsible for overseeing and coordinating all aspects of utilization review and insurance authorization for clients receiving substance use disorder (SUD) treatment at Britelife Recovery. This role ensures timely approvals and continued stay authorizations from insurance payers by effectively communicating clinical information and advocating for appropriate levels of care. The UR Specialist works closely with clinical staff, admissions, medical providers, and third-party payers to support patient access to treatment and maintain financial viability for the organization. Success in this role requires strong clinical judgment, documentation skills, familiarity with ASAM criteria, and a working knowledge of insurance guidelines specific to behavioral health What tasks are required? • Conduct initial and concurrent reviews for detox, residential, partial hospitalization (PHP), and intensive outpatient (IOP) levels of care., • Obtain prior authorizations and continued stay approvals from commercial and other payers by submitting timely clinical reviews and documentation., • Communicate clinical necessity of services based on ASAM criteria and DSM-5 diagnoses., • Track and document all insurance-related communications, decisions, and outcomes in the EHR and UR logs., • Collaborate with clinicians, therapists, case managers, and medical staff to gather accurate and up-to-date clinical information for reviews., • Ensure treatment plans, progress notes, and assessments are completed on time and accurately reflect medical necessity., • Participate in multidisciplinary team meetings to stay informed on client progress and treatment goals., • Assist staff with proper documentation practices to support insurance justification and compliance., • Maintain compliance with payer policies, HIPAA regulations, and internal utilization management protocols., • Monitor trends in denials, approvals, and length-of-stay metrics to support organizational performance improvement., • Assist in appeals and peer reviews by gathering required documentation and preparing clinical summaries., • Provide training and support to staff on documentation best practices related to utilization review., • Special projects as assigned What we need from you? • Minimum of 2–3 years of experience in utilization review, case management, or insurance coordination in a behavioral health or substance use treatment setting., • Knowledge of ASAM criteria and levels of care for substance use and co-occurring disorders., • Familiarity with managed care principles, insurance authorizations, and payer requirements., • Bachelor's degree in Nursing, Social Work, Psychology, or a related field required; advanced degree or licensure (e.g., RN, LCSW, LPC, LMHC, or CADC) preferred., • Excellent organizational, communication, and time management skills., • Proficiency in Electronic Health Records (EHRs), insurance portals, and Microsoft Office tools., • Bachelor's degree in Nursing, Social Work, Psychology, or a related field required; advanced degree or licensure (e.g., RN, LCSW, LPC, LMHC, or CADC) preferred., • Experience or working knowledge with Collaborative MD and KIPU, • Experience in detox and residential SUD programs., • Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna)., • Strong clinical writing skills and familiarity with medical necessity language., • Ability to advocate for clients while balancing payer relationships and compliance., • Ability to lift up to 25 pounds., • Ability to walk up and down stairs during emergency drills or situations. All ARS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. ARS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
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