Clinical Utilization & Authorization Specialist

Regional Economic Community Action Program, Inc.; City of Middletown (NY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Regional Economic Community Action Program, Inc. is seeking a detail-oriented Utilization Review Specialist to ensure clinical services are medically necessary, authorized, and compliant with NY OASAS, Medicaid Managed Care, and payer guidelines.

The role covers utilization management, clinical documentation review, revenue cycle support, and quality improvement across two NY-certified programs. The position requires collaboration with clinical staff, billing, managed care organizations, and

Qualifications

• Bachelor's degree in Social Work, Psychology, Human Services, Nursing, or a related behavioral health field required.
• Master’s degree preferred.
• One of the following credentials required: LMSW, LCSW, LMHC, CASAC, CASAC-AC, CASAC-MC, RN, or another Qualified Health Professional (QHP) recognized by NYS OASAS.
• Minimum of three (3) years of experience in behavioral health or substance use disorder treatment.
• Minimum of two (2) years of utilization review, case management, quality improvement, or managed care experience preferred.
• Experience working in an OASAS-certified program strongly preferred.
• Experience working with Medicaid Managed Care and commercial insurance plans required.
• Knowledge of ASAM Criteria required.
• Knowledge of OASAS regulations and applicable behavioral health requirements.
• Strong written, verbal, analytical, and interpersonal communication skills.
• Strong organizational and time-management skills with the ability to manage multiple deadlines.
• Strong attention to detail and ability to review complex clinical documentation.
• Ability to identify documentation deficiencies and communicate recommendations effectively.
• Ability to work collaboratively with multidisciplinary teams.
• Ability to maintain strict confidentiality and exercise sound judgment and discretion.
• Proficiency with Microsoft Office applications and electronic health records or other applicable database systems.
• Ability to work independently while also functioning effectively as part of a team.
• Ability to travel between RECAP locations as required.

Responsibilities

• Obtain initial service authorizations prior to admission when required by Medicaid Managed Care Organizations and commercial insurance plans.
• Complete concurrent reviews and continued-stay reviews within required payer timelines.
• Submit clinical documentation supporting medical necessity for requested services.
• Monitor authorization expiration dates and take appropriate action to support uninterrupted coverage.
• Coordinate peer-to-peer reviews when requested by insurance carriers.
• Prepare and submit reconsiderations and appeals for denied or reduced services.
• Maintain accurate authorization tracking logs and records.
• Monitor authorization outcomes and payer decisions.
• Notify appropriate clinical staff of authorization approvals, denials, limitations, and other payer determinations.
• Ensure utilization review activities are completed in accordance with payer requirements and applicable regulatory standards.

Skills

Attention to detail

Multidisciplinary collaboration

Strong communication

Analytical thinking

Education

Bachelor's degree in Social Work, Psychology, Human Services, Nursing, or related field

Master’s degree preferred

Licensure or certification (LMSW/LCSW/LMHC/CASAC/RN etc.)

Tools

Microsoft Office

Electronic health records (EHR)

Job description

Regional Economic Community Action Program, Inc. is seeking a detail-oriented Utilization Review Specialist to ensure clinical services are medically necessary, authorized, and compliant with NY OASAS, Medicaid Managed Care, and payer guidelines.

The role covers utilization management, clinical documentation review, revenue cycle support, and quality improvement across two NY-certified programs. The position requires collaboration with clinical staff, billing, managed care organizations, and