Description

The Utilization Review (UR) Specialist is responsible for managing the authorization process between HCANA facilities and third-party payers. This role ensures that all services provided—from detox to residential and intensive outpatient care—meet the criteria for medical necessity. The UR Specialist acts as a clinical advocate, utilizing clinical documentation to secure initial, concurrent, and retrospective authorizations, thereby ensuring the financial viability of the treatment provided and the continuity of care for our clients.

Requirements

• Authorization Management: Obtain and manage initial and concurrent authorizations for all levels of care. Monitor authorization end-dates to ensure timely clinical reviews.
• Clinical Advocacy: Conduct Live Reviews and Peer-to-Peer consultations with insurance company medical directors to advocate for continued stay or transitions in levels of care.
• Documentation Audit: Review clinical charts (KIPU EMR) for quality and compliance. Ensure that therapists and medical staff are documenting symptoms and progress that support medical necessity according to ASAM or other proprietary insurance criteria.
• Interdisciplinary Collaboration: Work closely with the Admissions, Clinical, and Medical teams to communicate insurance requirements, update staff on days authorized, and flag potential denials.
• Appeals & Peer-to-Peer Coordination: Manage the appeals process for denied claims, including gathering additional clinical evidence and scheduling physician-level reviews.
• Data Tracking & Reporting: Maintain accurate logs of authorized days, denial rates, and reimbursement trends. Provide weekly reports to leadership regarding the Census vs. Authorization status.
• Compliance: Ensure all UR activities are conducted in strict accordance with HIPAA

This job may require some after-hours work, as well as some hours on the weekend. For this reason, office hours may be flexible, with the option to work remotely, upon completion of training.

Prior Utilization Review or Billing experience in a substance use treatment or medical setting is a plus.

Prior experience with electronic medical records a plus, especially KIPU knowledge.

Knowledge of ASAM criteria a plus.

Requirements: 

• High school diploma or GED 
• 18 years of age or older.  
• Complete and pass pre-employment requirements, such as a background check and drug test, as outlined by HCANA policies.  
• Ability to set priorities, maintain accurate medical records on each client in accordance with the treatment plan and facility policies and procedures. 
• Strong interpersonal skills and ability to communicate with co-workers effectively and efficiently.