Ambrosia Behavioral Health is seeking an experienced Utilization Review (UR) Specialist to join our Revenue Cycle team in South Florida.
Ambrosia provides comprehensive behavioral health treatment for adults and adolescents across Mental Health and Substance Use Disorder programs, including Detoxification, Residential Treatment, and PHP levels of care.
We are looking for a seasoned UR professional who understands that excellent utilization review requires more than submitting authorizations. The right candidate knows how to present a clinically compelling case, anticipate payer objections, identify documentation gaps, advocate effectively for medically necessary treatment, and protect authorized treatment days.
Position Summary
The Utilization Review Specialist is responsible for managing initial and concurrent authorizations, communicating clinical information to payers, tracking authorized treatment days, supporting appeals and peer-to-peer reviews, and ensuring that clinical documentation supports medical necessity and the appropriate level of care.
This position works closely with Clinical, Medical, Admissions, Billing, Collections, and Revenue Cycle leadership.
The successful candidate will be organized, proactive, analytical, persistent with payers, and highly accountable for their assigned caseload.
Key Responsibilities
Complete initial authorization and concurrent review submissions accurately and within required payer timeframes.
Manage authorizations for Detox, Residential, and PHP levels of care across adult and adolescent Mental Health and SUD programs.
Review clinical documentation to ensure that it clearly supports medical necessity and continued level-of-care criteria.
Apply applicable clinical criteria, including ASAM and payer-specific medical necessity guidelines.
Communicate directly with insurance companies and utilization management departments regarding authorization requests and continued-stay reviews.
Maintain accurate tracking of authorized days, requested days, denied days, pending reviews, next review dates, and level-of-care changes.
Identify authorization gaps before services become unauthorized.
Escalate adverse determinations immediately when peer-to-peer review or appeal is appropriate.
Coordinate peer-to-peer reviews between payer medical directors and Ambrosia clinical/medical providers.
Prepare clinical information and support documentation for reconsiderations and appeals.
Track medical necessity, authorization and administrative denials and identify recurring payer trends.
Reconcile dates of service against authorized dates to prevent avoidable authorization-related claim denials.
Communicate documentation deficiencies promptly to therapists, nursing, medical providers and clinical leadership.
Participate in interdisciplinary treatment-team discussions when necessary to support continued-stay authorization.
Maintain detailed, contemporaneous documentation of all payer communications and authorization activity.
Work collaboratively with Billing and Collections to resolve authorization-related claim issues.
Maintain confidentiality and comply with HIPAA, AHCA, DCF, organizational and payer requirements.
Participate in payer audits and internal revenue-integrity reviews as needed.
Qualifications
Required:
Significant experience in behavioral health utilization review/utilization management
Strong experience working with commercial insurance payers
Experience obtaining initial and concurrent authorizations
Understanding of medical-necessity documentation
Experience with Mental Health and/or substance use disorder treatment
Excellent written and verbal communication skills
Strong organizational skills and ability to manage multiple concurrent authorization deadlines
Ability to independently identify problems, escalate issues and follow cases through resolution
Strong attention to detail and documentation accuracy
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