Analista de Serviços de Operações Jr. na Ipiranga planejando e programando a distribuição de combustíveis. Colaboração com transportadores e desenvolvimento de soluções logísticas.
AS
Hybrid Utilization Review Specialist – Substance Abuse Treatment Operations
Posted 3 months ago
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
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