Utilization Review Specialist

Ambrosia Treatment Center; West Palm Beach (FL); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive salary

Health benefits

Dental & Vision

PTO & Holidays

401(k)

Team culture

Job summary

Ambrosia Behavioral Health in West Palm Beach is seeking an experienced Utilization Review Specialist to join our Revenue Cycle team on-site. You will manage initial and concurrent authorizations, coordinate with payers, and ensure medical necessity and appropriate level of care for adults and adolescents.

The ideal candidate has significant UR experience in behavioral health, skilled communication with insurance payers, and meticulous, proactive case management for a multi-program setting.

Qualifications

• Significant experience in behavioral health utilization review.
• Experience working with commercial insurance payers.
• Understanding of medical necessity documentation and criteria.

Responsibilities

• Complete initial authorization and concurrent review submissions accurately and within required payer timeframes.
• Manage authorizations for Detox, Residential, and PHP across adult and adolescent MH/SUD programs.
• Review clinical documentation to support medical necessity and continued level-of-care.
• Apply ASAM and payer-specific medical necessity guidelines.
• Communicate with insurance companies and utilization management regarding requests and reviews.
• Maintain tracking of authorized days, requested days, denied days, pending reviews, and next review dates.

Skills

Behavioral health UR

Commercial payers experience

Initial & concurrent authorizations

Medical necessity documentation

Communication skills

Job description

This position is ON-SITE at the corporate office in West Palm Beach.
Ambrosia Behavioral Health is seeking an experienced Utilization Review (UR) Specialist to join our Revenue Cycle team in South Florida.
Ambrosia provides comprehensive behavioral health treatment for adults and adolescents across Mental Health and Substance Use Disorder programs, including Detoxification, Residential Treatment, and PHP levels 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 be organized, proactive, analytical, persistent with payers, and highly accountable for their assigned caseload.
Key Responsibilities

• Complete initial authorization and concurrent review submissions accurately and within required payer timeframes.
• Manage authorizations for Detox, Residential, and PHP levels of care across adult and adolescent Mental Health and SUD programs.
• Review clinical documentation to ensure that it clearly supports medical necessity and continued level-of-care criteria.
• Apply applicable clinical criteria, including ASAM 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 of authorized 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.
• Coordinate peer-to-peer reviews between 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.
• Reconcile dates of service against authorized dates to 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:

• Significant experience in behavioral health utilization review/utilization management
• 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
• Ability to pass a level 2 background check: HB531 | Florida Agency for Health Care Administration

Highly Preferred:

• 5+ years of behavioral health UR experience
• Experience with Detox, Residential and PHP
• Experience with both adult and adolescent behavioral health
• Knowledge of ASAM 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 under AHCA and/or DCF licensure
• Clinical background or licensure such as RN, LCSW, LMHC or LMFT

What We Offer

• Competitive salary
• Health benefits with no co-pay or deductible
• Dental and vision benefits
• PTO and paid holidays
• 401 K
• Supportive team culture