Assessment & Utilization Review (UR) Clinician

Job Description

Job Description

Description:

Position Summary

The Assessment & Utilization Review (UR) Clinician is responsible for completing comprehensive behavioral health and substance use disorder intake assessments and coordinating insurance authorization requirements throughout the client’s course of treatment.

This position serves as a link between the clinical team, administrative/billing staff, and insurance payers to help ensure clients are placed in the appropriate level of care, services remain medically necessary, and required prior authorizations and continued-stay authorizations are completed accurately and on time.

The ideal candidate is an independently licensed behavioral health clinician, preferably an LISW or LPCC, with experience in behavioral health and/or substance use disorder treatment, clinical assessment, medical necessity, and insurance utilization review.

Essential Job ResponsibilitiesIntake & Clinical Assessment

• Complete comprehensive intake and diagnostic assessments for individuals seeking behavioral health and/or substance use disorder services.
• Review presenting concerns, behavioral health history, substance use history, medical information, psychosocial needs, risk factors, functional needs, and other relevant clinical information.
• Identify appropriate diagnoses within the clinician’s professional scope of practice.
• Determine recommended services and level of care based on the client’s assessed needs.
• Complete or coordinate applicable level-of-care assessments, including ASAM criteria when appropriate.
• Identify immediate safety concerns, clinical risks, and needs requiring additional evaluation or referral.
• Work with the treatment team to support timely admission and transition into services.

Prior Authorization & Utilization Review

• Complete initial insurance prior authorization requests for services requiring payer approval.
• Complete continued-stay reviews, concurrent reviews, and re-authorization requests within required payer timeframes.
• Gather clinical information from treatment plans, progress notes, assessments, attendance records, outcome measures, and treatment team members to support authorization requests.
• Clearly demonstrate medical necessity, treatment progress, continued needs, and level-of-care justification in authorization submissions.
• Track authorization effective dates, approved units or days, expiration dates, and re-authorization deadlines.
• Monitor utilization to help prevent services from exceeding authorized units or dates.
• Maintain current knowledge of authorization and utilization requirements for Medicaid, Medicaid Managed Care Organizations, and other contracted insurance plans.
• Respond to payer requests for additional clinical information.
• Participate in peer reviews or clinical reviews with insurance companies when appropriate and within the clinician’s scope.
• Assist with authorization denials by identifying missing information, coordinating additional documentation, and supporting reconsideration or appeal processes as appropriate.
• Communicate authorization decisions, limitations, and payer requirements to the treatment and billing teams.

Ongoing Clinical Monitoring

• Review client utilization throughout treatment to ensure services remain consistent with the client’s clinical needs, treatment plan, level of care, and payer requirements.
• Monitor clients approaching authorization limits or continued-stay review dates.
• Identify cases where documentation may not sufficiently demonstrate continued medical necessity and work with clinicians to address concerns.
• Review treatment progress and barriers to determine whether the current intensity of services remains appropriate.
• Support appropriate transitions between levels of care, including step-down, discharge, or referral to alternative services.
• Help identify patterns involving authorization denials, reduced authorization periods, or payer concerns that may require organizational follow-up.

Treatment Team Participation

• Serve as an active member of the interdisciplinary treatment team.
• Participate in treatment team meetings, case consultations, continued-stay reviews, and discharge planning as needed.
• Collaborate with counselors, social workers, case managers, substance use disorder professionals, clinical supervisors, medical providers, and other team members.
• Provide feedback regarding medical necessity, level of care, treatment progress, and insurance requirements.
• Assist the treatment team in identifying clinical documentation needed to support continued authorization of services.
• Promote coordination between assessment, treatment planning, service delivery, utilization review, and discharge planning.

Documentation & Compliance

• Complete assessments, authorization documentation, and utilization review activities accurately and within established timeframes.
• Maintain organized records of authorization submissions, approvals, denials, expiration dates, and payer communications.
• Ensure clinical information submitted to payers accurately reflects the services documented in the client record.
• Follow applicable Medicaid, payer, organizational, confidentiality, and documentation requirements.
• Participate in quality improvement activities related to authorization outcomes, utilization, documentation, and access to care.
• Assist leadership in identifying trends that may impact reimbursement, service delivery, or client access to treatment.

Requirements:

Preferred Qualifications

• Current Ohio LISW or LPCC license preferred
• LSW or LPC may be considered based on experience and scope of responsibilities
• Master’s degree in social work, counseling, or a related behavioral health field
• Experience providing behavioral health and/or substance use disorder services
• Experience completing diagnostic assessments and determining appropriate levels of care
• Knowledge of Medicaid, managed care organizations, and commercial insurance requirements preferred
• Experience with prior authorization, utilization review, or concurrent review strongly preferred
• Familiarity with ASAM criteria for substance use disorder services preferred
• Strong clinical documentation, organization, and communication skills
• Ability to manage multiple authorization deadlines and payer requirements

Knowledge & Skills

The successful candidate should have a strong understanding of:

• Behavioral health and substance use disorder assessment
• Diagnostic formulation and treatment recommendations
• Medical necessity and level-of-care criteria
• ASAM criteria when applicable
• Treatment planning and continued-stay criteria
• Medicaid and managed care authorization processes
• Clinical documentation requirements
• Prior authorization and re-authorization processes
• Utilization management and concurrent review
• Interdisciplinary treatment planning
• Confidentiality and HIPAA requirements
• Behavioral health payer and regulatory requirements

The position also requires excellent written communication, attention to detail, clinical judgment, time management, and the ability to communicate effectively with both clinical staff and insurance reviewers.

Performance Expectations

Success in this position includes:

• Intake assessments completed accurately and within established timeframes
• Prior authorization requests submitted before required deadlines
• Re-authorizations completed before existing authorizations expire
• Accurate tracking of authorized units, days, and service periods
• Reduction in authorization-related service interruptions
• Strong documentation supporting medical necessity and continued treatment
• Timely communication of authorization decisions to treatment and billing teams
• Active participation in treatment team and level-of-care decisions
• Identification of utilization or payer issues before they result in avoidable denials