Utilization Review Specialist

Ambrosia Treatment Center; West Palm Beach (FL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health benefits

No co-pay or deductible

Paid time off

Job summary

Ambrosia Behavioral Health in West Palm Beach, FL is seeking a seasoned Utilization Review Specialist to join our Revenue Cycle team. You will manage initial and concurrent authorizations and coordinate with payers to ensure medical necessity and appropriate levels of care.

The ideal candidate has extensive UR experience in behavioral health, strong written and verbal communication, and a track record of effective payer negotiations and appeals.

Qualifications

• 5+ years of behavioral health UR experience.
• Experience with Detox, Residential and PHP.
• Proven ability to obtain initial and concurrent authorizations.
• Strong communication and organizational skills; healthcare payer liaison.

Responsibilities

• Submit initial authorization and concurrent reviews within payer timelines.
• Manage authorizations across Detox, Residential, and PHP for adults and adolescents.
• Review documentation to ensure medical necessity and level of care.
• Communicate with payers and manage appeals and peer-to-peer reviews.
• Maintain detailed payer communications and track authorized days.

Skills

UR experience

Payer communications

ASAM criteria

Medical necessity

Detox/Residential/PHP

Adolescent/Adult BH

Documentation accuracy

Attention to detail

Education

RN licensure

LCSW

LMHC

LMFT

Tools

MCG criteria

InterQual

payer criteria

Job description

This position is ON-SITE at the corporate office in West Palm Beach.

Ambrosia Behavioral Health is seeking an experiencedUtilization Review (UR) Specialistto join our Revenue Cycle team in South Florida.

Ambrosia provides comprehensive behavioral health treatment foradults and adolescentsacross Mental Health and Substance Use Disorder programs, includingDetoxification, Residential Treatment, and PHPlevels of care.

We are looking for a seasoned UR professional who understands that excellent utilization review requires more than submitting authorizations. The right candidate knows how to present a clinically compelling case, anticipate payer objections, identify documentation gaps, advocate effectively for medically necessary treatment, and protect authorized treatment days.

Position Summary

The Utilization Review Specialist is responsible for managing initial and concurrent authorizations, communicating clinical information to payers, tracking authorized treatment days, supporting appeals and peer-to-peer reviews, and ensuring that clinical documentation supports medical necessity and the appropriate level of care.

This position works closely with Clinical, Medical, Admissions, Billing, Collections, and Revenue Cycle leadership.

The successful candidate will beorganized, proactive, analytical, persistent with payers, and highly accountable for their assigned caseload.

Key Responsibilities

• Completeinitial authorization and concurrent review submissionsaccurately and within required payer timeframes.
• Manage authorizations forDetox, Residential, and PHPlevels of care across adult and adolescent Mental Health and SUD programs.
• Review clinical documentation to ensure that it clearly supportsmedical necessity and continued level-of-care criteria.
• Apply applicable clinical criteria, includingASAM and payer-specific medical necessity guidelines.
• Communicate directly with insurance companies and utilization management departments regarding authorization requests and continued-stay reviews.
• Maintain accurate tracking ofauthorized days, requested days, denied days, pending reviews, next review dates, and level-of-care changes.
• Identify authorization gaps before services become unauthorized.
• Escalate adverse determinations immediately when peer-to-peer review or appeal is appropriate.
• Coordinatepeer-to-peer reviewsbetween payer medical directors and Ambrosia clinical/medical providers.
• Prepare clinical information and support documentation for reconsiderations and appeals.
• Track medical necessity, authorization and administrative denials and identify recurring payer trends.
• Reconciledates of service against authorized datesto prevent avoidable authorization-related claim denials.
• Communicate documentation deficiencies promptly to therapists, nursing, medical providers and clinical leadership.
• Participate in interdisciplinary treatment-team discussions when necessary to support continued-stay authorization.
• Maintain detailed, contemporaneous documentation of all payer communications and authorization activity.
• Work collaboratively with Billing and Collections to resolve authorization-related claim issues.
• Maintain confidentiality and comply with HIPAA, AHCA, DCF, organizational and payer requirements.
• Participate in payer audits and internal revenue-integrity reviews as needed.

Qualifications

Required:

• Strong experience working with commercial insurance payers
• Experience obtaining initial and concurrent authorizations
• Understanding of medical-necessity documentation
• Experience with Mental Health and/or substance use disorder treatment
• Excellent written and verbal communication skills
• Strong organizational skills and ability to manage multiple concurrent authorization deadlines
• Ability to independently identify problems, elevate issues and follow cases through resolution
• Strong attention to detail and documentation accuracy
• 5+ years of behavioral health UR experience
• Experience withDetox, Residential and PHP
• Experience with bothadult and adolescent behavioral health
• Knowledge ofASAM criteria
• Familiarity with MCG, InterQual and payer-specific clinical criteria
• Experience with appeals, reconsiderations and peer-to-peer reviews
• Experience with Florida behavioral health providers operating underAHCA and/or DCF licensure
• Clinical background or licensure such asRN, LCSW, LMHC or LMFT

What We Offer

Health benefits with no co-pay or deductible

Our clinicians and support teams work together to care for people facing mental health and substance use challenges. We offer professional development, health insurance options, and paid time off.

Our Human Resources team can help with open roles and the application process.