Utilization Review (UR) Specialist

Job Description

About Us

Welcome to ClearMind Talent, where we believe in accelerating our clients towards new heights while forging paths to streamline productivity. Our mission is to connect behavioral health organizations with unparalleled, reliable, and talented professionals, ensuring a fulfilling and reliable experience for all.

Reports To: Utilization Review Manager / Admissions Director

Job Summary

The Utilization Review (UR) Specialist is responsible for ensuring that all behavioral health services provided meet the criteria for medical necessity established by third-party payers and managed care organizations. This role involves clinical documentation review, submitting timely authorization requests, and conducting persuasive clinical reviews to secure continued payment for client services.

Key Responsibilities

• Conduct thorough reviews of client clinical documentation to ensure it accurately and comprehensively supports the medical necessity for the current level of care.
• Submit timely initial and concurrent review requests to insurance companies, providing the necessary clinical documentation to secure authorization for treatment.
• Engage in peer-to-peer (P2P) review calls with insurance medical directors, effectively communicating the clinical rationale and necessity for continued stay/service delivery to prevent denials.
• Track all authorizations, denials, and appeals, maintaining meticulous records of communication and payer criteria.
• Collaborate closely with the clinical team, educating them on payer requirements and documentation standards necessary to support continued authorization.
• Process and manage all denial and appeal correspondence efficiently and proactively.

Qualifications

• Bachelor’s degree in a behavioral health or healthcare-related field (e.g., Social Work, Nursing, Psychology).
• Current state licensure/certification as a clinical professional (e.g., LPN, RN, LPC-A, LCSW-A, or equivalent) is highly preferred.
• Minimum of 1 year of experience specifically in Utilization Review or Case Management within a behavioral health setting (detox, residential, or PHP/IOP).
• Expert knowledge of ASAM Criteria or other level-of-care placement guidelines.
• Strong understanding of medical necessity criteria, managed care processes, and clinical documentation requirements.

Equal Opportunity Employment (EOE) Statement

ClearMind Talent is an Equal Opportunity Employer (EOE). We celebrate diversity and are committed to creating an inclusive environment for all employees and candidates. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected characteristic.