Job description
Bradford Health Servicesprovides addiction treatment programs, resources, and community for every aspect of recovery. Through our premier drug and alcohol rehab facilities across the Southeast, we provide affordable, evidence-based addiction treatment with proven outcomes at every level of care. We’re guided by unity and dedicated to meeting and treating every patient right where they are. Bradford is more than a healthcare network; we are recovery communities for every stage of the journey.
We are seeking a Utilization Review Specialist to add to our dynamic team! The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.
Responsibilities
Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with payer requirements and established departmental workflows
Obtain, document, and monitor authorizations across the continuum of care, including approved level of care, number of units or days, effective dates, review dates, authorization numbers, and payer-specific conditions
Review the medical record and collaborate with the treatment team to obtain complete, accurate, and timely clinical information supporting medical necessity and the requested level of care
Present clinical information to payer representatives clearly, objectively, and persuasively, using applicable medical-necessity criteria and payer guidelines
Maintain accurate authorization records in the electronic medical record, payer portals, tracking systems, and other designated applications
Monitor assigned caseloads and authorization deadlines daily; complete required follow-up and escalate unresolved payer, documentation, or authorization barriers before reimbursement is placed at risk
Identify clinical documentation gaps or inconsistencies and communicate specific needs to the appropriate clinician, provider, or leader without directing clinical care or altering the clinical record
Coordinate with clinical and case-management teams regarding anticipated transitions, discharge planning, and changes in level of care to support continuity of treatment and timely payer notification
Recognize potential adverse determinations and promptly escalate cases requiring peer-to-peer review, reconsideration, appeal, or leadership intervention
Prepare concise case summaries and supporting documentation for peer reviews, appeals, and other payer escalation activities as assigned
Review payer correspondence and adverse determinations for accuracy, communicate outcomes to appropriate stakeholders, and complete required follow-up within established deadlines
Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives
Follow standardized utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states
Maintain working knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and assigned service-line requirements
Collaborate professionally with Utilization Review leadership, Centralized Admissions, Clinical Directors, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and other Revenue Cycle partners
Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies
Perform other duties as assigned in support of Utilization Review and Revenue Cycle objectives
Minimum Qualifications
High school diploma or equivalent required; relevant college coursework, professional certification, or equivalent directly related experience strongly preferred
Minimum 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related function.
Behavioral Health and/or Substance Use Disorder experience required.
Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up.
Ability to interpret clinical documentation and clearly communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge.
Demonstrated ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation.
Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality.
Working knowledge of HIPAA and 42 CFR Part 2 requirements.
Preferred Qualifications
Bachelor's degree in Social Work, Psychology, Counseling, Nursing, Healthcare Administration, Health Information Management, or a related healthcare discipline
Minimum 1 year of direct utilization review, concurrent review, or payer authorization experience within behavioral health or substance use disorder treatment
Knowledge of ASAM Criteria and experience with residential, inpatient, partial hospitalization, intensive outpatient, and outpatient levels of care
Experience working with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers
Experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals
Active clinical license or relevant certification, such as RN, LPN/LVN, LMSW, LPC, CADC, LADAC, CCM, or an equivalent credential, preferred but not required
Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications
We’re officially a Great Place to Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place to Work® Certification - based entirely on feedback from our own employees. Read more here:
At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.
Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
Student Loan Repayment – Available for nurses and therapists.
Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
Generous PTO – A robust paid time off policy to support work-life balance.
Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.