Utilization Review Specialist: Drive Compliance & Quality Care

ADDICTION AND MENTAL HEALTH SERVICES; United States; Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Medical Coverage

PTO

Retirement Benefits

Mental Health Support

Voluntary Benefits

Job summary

Bradford Health Services is seeking a Utilization Review Specialist in the United States to ensure medical necessity and regulatory compliance across addiction treatment programs. You will analyze patient records, treatment plans, and clinical data to determine appropriate care levels and efficient resource use.

You will collaborate with clinicians, insurers, and case managers to secure timely approvals, maintain accurate authorization records, and meet deadlines while upholding patient

Qualifications

• High school diploma or equivalent; college coursework, certification, or related experience preferred.
• Minimum 2 years in behavioral healthcare, utilization review, or related field.
• Behavioral Health or Substance Use Disorder experience required.
• Understanding of insurance authorization processes (precertification, concurrent review, continued-stay).
• Ability to interpret clinical documentation and communicate findings clearly.

Responsibilities

• Complete admissions, precertification, concurrent, continued-stay, step-down, and retrospective reviews per payer requirements.
• Obtain and monitor authorizations across care continuum with accurate details.
• Review medical records and collaborate with treatment teams for medical necessity.
• Present clinical information to payers using criteria and guidelines.
• Maintain accurate authorization records in EMR, payer portals, and tracking systems.
• Monitor caseloads and deadlines; escalate barriers to avoid reimbursement risk.
• Identify documentation gaps and communicate needs to clinicians or leaders.
• Coordinate with care teams on transitions and discharge planning.
• Escalate adverse determinations for peer-to-peer reviews or appeals.

Skills

Communication skills

Attention to detail

Time management

HIPAA knowledge

Education

Bachelor's degree in related healthcare field

Active clinical license or relevant certification

Tools

EMR systems

Payer portals

Microsoft Office

Job description

Bradford Health Services is seeking a Utilization Review Specialist in the United States to ensure medical necessity and regulatory compliance across addiction treatment programs. You will analyze patient records, treatment plans, and clinical data to determine appropriate care levels and efficient resource use.

You will collaborate with clinicians, insurers, and case managers to secure timely approvals, maintain accurate authorization records, and meet deadlines while upholding patient