Job Description

Job Description

Job Description

This is an in office position and must have prior UR & clinical experience. Remote hires and applicants without prior experience will not be considered.

A growing, reputable provider of specialized medical billing services for behavioral health and substance abuse treatment centers is seeking an experienced Utilization Review (UR) Specialist to join our dynamic and fast-paced team. This is a confidential opportunity ideal for a professional with 5+ years of clinical experience and a strong background in utilization review.

The selected candidate will play a vital role in connecting clinical care delivery with revenue cycle outcomes. This position requires advanced clinical reasoning, payer knowledge, and the ability to act as a liaison between treatment providers and insurance companies.

Key Responsibilities

Clinical Advocacy

• Advocate for patients by presenting strong clinical justifications to insurance payers.
• Apply medical necessity criteria to obtain and maintain authorizations across all levels of care.
• Resolve complex authorization issues with proactive thinking and problem-solving.

Facility Collaboration & Clinical Quality Management

• Partner with treatment center clinical teams to align care plans with payer requirements.
• Offer guidance on documentation improvements and trends in payer behavior.
• Serve as the main liaison between providers and the billing team to ensure smooth coordination.

Communication & Case Management

• Communicate clearly and professionally with facility staff, insurance representatives, and internal teams.
• Manage a caseload of 50–70 patients, ensuring timely follow-ups and precise documentation.
• Maintain thorough and up-to-date records in EMR (Kipu required) and authorization trackers.
• Escalate denied or pended cases as needed via peer reviews or appeals.

Operational Excellence & Technology Utilization

• Utilize EMR systems (Kipu required) and Google Workspace tools (Docs, Sheets, Drive).
• Support after-hours utilization reviews to ensure continuity and compliance.
• Stay informed on payer policy changes and communicate updates to partner facilities.

Requirements

• Minimum 5 years of clinical experience in behavioral health or substance abuse settings.
• Significant experience in utilization review required (not entry-level).
• Proficiency with Kipu EMR and Google Workspace.
• Strong organizational and communication skills.
• Strong verbal and written communication skills with both internal teams and external payers.
• Ability to multitask, stay organized, and manage a large caseload efficiently.
• Customer service mindset—ability to foster strong relationships with facilities and serve as a trusted resource.
• Understanding that UR is not just about approvals—it’s about clinical integrity, compliance, and bridging the gap between care teams and financial sustainability

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