Job Type: Full-Time

Department: Clinical Operations / Utilization Management

Reports To: Utilization Review Manager

Position Summary:

We are seeking a detail-oriented and highly organized Utilization Review (UR) Specialist to join our Behavioral Health team. The ideal candidate will be responsible for supporting clinical decision-making and utilization management processes through meticulous data entry, documentation review, and coordination with internal and external stakeholders. This role plays a vital part in ensuring timely and accurate authorization and review of behavioral health services while maintaining compliance with payer and regulatory requirements.

Key Responsibilities:

• Review patient clinical documentation to determine medical necessity for behavioral health services.

• Collaborate with clinicians to gather additional information when required.

• Submit timely authorization requests to insurance companies or third-party administrators.

• Accurately enter clinical data, patient information, and authorization outcomes into electronic health records (EHR) and UR tracking systems.

• Maintain up-to-date logs of all utilization review activities, including approval/denial status, payer communications, and relevant deadlines.

• Perform quality checks to ensure data accuracy, completeness, and compliance with organizational standards.

• Interface with insurance providers to verify benefits, submit clinical reviews, and follow up on authorizations.

• Ensure compliance with HIPAA, state, and federal regulations governing behavioral health and UR processes.

• Assist in generating weekly and monthly reports related to authorization volumes, turnaround times, and denial trends.

• Support audit requests by compiling required documentation and logs.

Required Qualifications:

• High School Diploma or GED required; Associate’s or Bachelor’s degree in Psychology, Health Sciences, or related field preferred.

• 1–2 years of experience in utilization review, medical billing, insurance authorization, or behavioral health services.

• Proficient in data entry with strong attention to detail (minimum 50 WPM preferred).

• Experience working with EHR systems (e.g., CareLogic, Credible, Epic, etc.).

• Knowledge of insurance processes, including Medicaid, Medicare, and commercial payers.

• Strong organizational and time management skills with the ability to manage multiple priorities.

Preferred Skills & Competencies:

• Familiarity with DSM-5 diagnostic criteria and behavioral health terminology.

• Ability to read and understand clinical documentation such as treatment plans and progress notes.

• Proficient in Microsoft Office Suite (Excel, Word, Outlook).

• Team-oriented mindset with effective written and verbal communication skills.

• Capable of working in a fast-paced, deadline-driven environment.

Work Environment:

• Standard office setting or remote work, depending on location.

• Regular use of computer and telephone systems.

• May require flexible scheduling to meet urgent utilization review timelines.

Why Join Us?

• Meaningful work that directly impacts client care and outcomes.

• A supportive team culture with opportunities for growth and development.

• Competitive compensation and benefits package.