Utilization Review Specialist
Status: Full-Time, 40 hours per week
Schedule: Monday–Friday, approximately 8:00 AM–4:00 PM
Pay Range: $33–$41 per hour (based on experience)
The Utilization Review Specialist reviews each patient’s care at regular intervals from admission through discharge by evaluating the medical record and collaborating with members of the interdisciplinary team. The purpose of this review is to determine medical necessity, appropriateness of level of care, quality of services, and length of stay. Performance is reflected through patient outcomes, payer compliance, and authorization success.
This role participates in interdisciplinary clinical team meetings to discuss active treatment, discharge planning, and ongoing medical necessity requirements for insurance reimbursement. The Utilization Review Specialist gathers and communicates clinical updates requested by health plans in a timely and accurate manner.
Key Responsibilities:
Review medical record documentation to ensure continued stay is medically necessary and appropriate.
Participate in interdisciplinary treatment team meetings to support treatment planning and discharge coordination.
Perform timely telephonic clinical reviews with insurance carriers for initial and continued stay authorizations.
Maintain accurate written and electronic documentation of authorizations and payer communications.
Attend Utilization Review committee meetings and maintain meeting minutes.
Communicate utilization review issues and potential denials to the UR Director and physicians in a timely manner.
Facilitate peer-to-peer reviews with insurance carriers when needed.
Notify the clinical team and business office of authorization denials or changes.
Assist with the appeals process for insurance denials and document outcomes.
Compile and maintain utilization data, including length of stay and discharge metrics, as requested by managed care contracts.
Communicate payer policy changes or concerns to the UR Director and Hospital CEO.
Assist the UR Director with data compilation and reporting as needed.
Facilitate clarification of patient benefits and authorizations for acute and diversionary psychiatric care and related medical services.
Qualifications:
Active licensure as LPN, RN, LICSW, or LMHC
Master’s degree in a related field preferred
Minimum of 2 years of utilization review, care management, or utilization management experience preferred
Strong clinical documentation review skills and working knowledge of insurance authorization processes
Ability to collaborate effectively with clinical teams, physicians, and insurance carriers
Strong organizational, communication, and time-management skills
Headquartered in Franklin, Tennessee, Acadia Healthcare was established in January 2005 to develop and operate a network of behavioral health facilities across the country.
Acadia Healthcare’s mission is to create a world-class organization that sets the standard of excellence in the treatment of specialty behavioral health and addiction disorders.
Acadia’s management style and philosophy is one of collaboration and flexibility as we create an energetic and team-oriented service delivery system. Our organization values input from employees, physicians, and all strategic alliances. As evidenced in our mission statement, Acadia Healthcare’s mission is to create behavioral health centers where people receive care that enables them to regain hope in a supportive, caring environment. We want Acadia to be synonymous with excellent care, phenomenal customer service and an unparalleled commitment to our patients, staff, physicians, and community.
As a leading provider of behavioral healthcare services in the United States and Puerto Rico, Acadia Healthcare operates 253 treatment facilities across 39 states. Our network of treatment facilities offers multiple levels of care for various behavioral health and substance use disorders. At Acadia, our primary goal is to meet patients where they’re at in their treatment process. We do this by providing a multitude of levels of care, including detoxification, residential treatment for addiction, residential treatment for dual diagnosis, acute psychiatric inpatient hospitalization, medication-assisted treatment (MAT) services, and an array of outpatient programming options, ranging from partial hospitalization programs (PHPs) and intensive outpatient programs (IOPs) to traditional outpatient services. Our network of treatment facilities creates greater access to care, reduces the stigma associated with mental illness and addiction, and offers those in our communities a safe environment in which to receive the treatment they need.
