Clinical Utilization & Documentation Specialist

Regional Economic Community Action Program Inc; City of Middletown (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

Regional Economic Community Action Program Inc seeks a dedicated Utilization Review Specialist to ensure services are medically necessary, properly authorized, and compliant with NY OASAS regulations and payer guidelines.

You will collaborate with clinical and billing teams across two NYS-certified programs, managing authorizations, documentation, and appeals to support reimbursement and quality improvement.

Qualifications

• Experience applying utilization management principles and payer guidelines.
• Ability to review medical records to determine medical necessity.
• Familiarity with regulatory standards and ASAM Criteria where applicable.
• Strong communication skills with clinical staff and payers.

Responsibilities

• Lead utilization management to obtain authorizations prior to admission when required.
• Perform concurrent and continued-stay reviews within payer timelines.
• Submit supporting documentation for medical necessity and payor appeals as needed.
• Maintain authorization tracking and document payer decisions and outcomes.
• Coordinate with clinicians to improve documentation for compliance and reimbursement.
• Educate staff on documentation requirements and best practices.

Skills

Utilization management

Clinical documentation review

Regulatory compliance

Payer communication

Job description

Regional Economic Community Action Program Inc seeks a dedicated Utilization Review Specialist to ensure services are medically necessary, properly authorized, and compliant with NY OASAS regulations and payer guidelines.

You will collaborate with clinical and billing teams across two NYS-certified programs, managing authorizations, documentation, and appeals to support reimbursement and quality improvement.