Hybrid Utilization Review Specialist – Substance Abuse Treatment Operations

at ALL IN SOLUTIONS

• Job title: Utilization Review Specialist – Substance Abuse Treatment Operations
• Job type: Full Time
• Experience level: Junior, Mid level
• Salary: $50,000 - $60,000 per year
• Degree requirement: Bachelor's Degree
• Tech skills: PHP
• Location requirements: Hybrid, Boynton Beach, United States

About the role

• Utilization Review Specialist ensuring compliance in behavioral health treatment operations. Conducting authorizations and maintaining UR documentation for substance abuse programs.

Responsibilities

• Conduct and submit timely and accurate pre-certifications, concurrent reviews, and continued stay authorizations for clients across all levels of care (Detox, Residential, PHP, IOP).
• Proficiently utilize and document against established medical necessity criteria, including ASAM Criteria, LOCUS, and InterQual, to support clinical justification for treatment.
• Prepare and submit clear, clinically sound documentation for the initial stages of denial appeal and grievance processes.
• Maintain detailed and organized UR documentation within the Electronic Medical Record (EMR), ensuring all records are audit-ready and compliant with internal and external standards.
• Serve as a knowledgeable and professional point of contact for routine communications with payer representatives (insurance companies) regarding authorization requests and follow-up.
• Collaborate with the UR Manager and clinical team to ensure documentation supports full compliance with state licensing regulations (NJ DOH, FL DCF, CA DHCS) and accreditation standards (CARF/Joint Commission).
• Maintain current knowledge of relevant changes to payer guidelines, medical necessity criteria, and state/federal regulations that impact UR processes.

Requirements

• Bachelor’s degree in Healthcare Administration, Social Work, Nursing, Psychology, or a related field strongly preferred (or equivalent professional experience).
• Minimum of 2 years of proven, hands-on utilization review or case management experience in an inpatient behavioral health or SUD setting.
• Direct experience and proficiency in applying ASAM Criteria for patient placement and continued stay justification.
• Demonstrated ability to write clear, compelling clinical justifications for review submissions.
• Proficiency with Kipu EMR systems and general UR tracking/submission tools is highly preferred.

Benefits

• None specified