Utilization Review Specialist

Job Title: Utilization Review Specialist
Department: Clinical
Physical Location: Lovett Center Residential SUD Facility

Facility: Prairie Recovery Center and Lovett Center

Reports To: VP of Client Services
Job Type: Full-Time
Salary: Based on experience and credentials

Position Summary:

The Utilization Review (UR) Specialist is responsible for managing the medical necessity review process for clients in our detox and residential substance use disorder (SUD) treatment program. As well as our Mental Health and Substance Use Disorder IOP.  This role ensures that services provided are in alignment with payer requirements, clinically appropriate, and adequately documented to support reimbursement. The UR Specialist works closely with clinical staff and insurance companies to advocate for client care and maintain program compliance.

Key Responsibilities:

• Conduct initial and ongoing concurrent reviews of client charts to determine medical necessity for detox and residential SUD treatment.


• Conduct initial and ongoing concurrent reviews of client charts to determine medical necessity for Mental Health and SUD IOP.


• Submit timely and accurate clinical reviews to insurance companies for authorization of services.


• Monitor authorizations and track continuing stay reviews and coverage periods.


• Collaborate with therapists, case managers, and nursing staff to gather relevant clinical documentation for reviews.


• Communicate with payers to advocate for clients’ continued treatment and address any coverage denials or issues.


• Assist in appeals process for denied authorizations, preparing documentation and follow-up communications as needed.


• Maintain detailed records of all reviews, communications, and authorizations in accordance with HIPAA and organizational policies.


• Identify and communicate documentation gaps or compliance concerns to the clinical team.


• Participate in UR or QA meetings and contribute to continuous improvement of documentation and care practices.


• Stay informed on payer requirements, UR policies, and regulatory changes in behavioral health and SUD services.

Qualifications:

• Education: Bachelor’s degree in a healthcare-related field required. Master’s degree or licensure (LPC, LMSW, LCSW, LMFT, RN, or equivalent) preferred.


• Experience: Minimum of 2 years of experience in utilization review, case management, or behavioral health/substance use disorder treatment.


• Knowledge:
  
  
  
  • Strong understanding of ASAM, DSM-V, TAC criteria and clinical documentation standards.
  
  
  • Familiarity with insurance authorization processes and medical necessity criteria for SUD treatment.
  
  
  • Familiarity with insurance authorization processes and medical necessity criteria for Mental health treatment
  
  
  • Working knowledge of HIPAA, payer guidelines, and clinical best practices.
  
  
  
  


• Skills:
  
  
  
  • Excellent communication and advocacy skills, both written and verbal.
  
  
  • High attention to detail and organizational skills.
  
  
  • Ability to work independently and as part of a multidisciplinary team.
  
  
  • Proficiency with electronic health records (EHRs) and insurance portals.
  
  
  
  

Preferred Qualifications:

• Experience in residential or inpatient substance use treatment setting.


• Experience with major commercial payers.


• Certification in Utilization Review, Case Management, or Quality Assurance a plus.

Work Environment:

• Local Office-based with regular interaction with clinical and administrative teams.


• Hybrid schedule available.