Clinical Utilization Review Specialist

Bradford Health Services; United States; On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical coverage

PTO

401(k) plan

Mental health support

Voluntary insurance options

Student loan repayment

Job summary

Bradford Health Services seeks a dedicated Utilization Review Specialist to ensure medical necessity and regulatory compliance across our U.S. facilities. You will review patient records and treatment plans, collaborate with treatment teams, and support timely payer authorizations.

The role emphasizes accurate documentation, adherence to HIPAA and payer guidelines, and proactive problem solving to optimize patient outcomes while controlling costs.

Qualifications

• High school diploma or equivalent; college coursework or certification preferred.
• Minimum 2 years in behavioral healthcare, substance use disorder treatment, utilization review, managed care, or related field.
• Experience with insurance authorization processes and payer follow-up.
• Working knowledge of HIPAA and 42 CFR Part 2 requirements.

Responsibilities

• Complete admission, precertification, concurrent, continued-stay, and retrospective reviews per payer requirements.
• Obtain and monitor authorizations across the continuum of care with details.
• Review medical records and collaborate with the treatment team to support medical necessity.
• Present clinical information to payer representatives using medical-necessity criteria.
• Maintain authorization records in EMR, payer portals, and tracking systems.
• Monitor caseloads and deadlines; escalate barriers to avoid reimbursement risk.

Skills

Verbal communication

Written communication

HIPAA knowledge

Payer authorization

Case management

Education

Bachelor's degree

Tools

EMR systems

Payer portals

Microsoft Office

Job description

Bradford Health Services seeks a dedicated Utilization Review Specialist to ensure medical necessity and regulatory compliance across our U.S. facilities. You will review patient records and treatment plans, collaborate with treatment teams, and support timely payer authorizations.

The role emphasizes accurate documentation, adherence to HIPAA and payer guidelines, and proactive problem solving to optimize patient outcomes while controlling costs.