Utilization Review Specialist

Utilization Review Specialist – Exact Billing Solutions (EBS) Lauderdale Lakes, FL - On-site - No Remote Salary: $55K - $70K About the Role As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources. The UR Records Specialist will assist in reviewing and processing records to submit for authorization to the payors. This position collaborates closely with clinical teams, insurance providers, and other healthcare professionals to support efficient and effective patient care. Key Responsibilities Review and analyze clinical records, including received documentation from payors, to ensure compliance with ABA therapy best practices and insurance requirements. Accurately input and maintain clinical records, authorization requests, and related documents into the electronic health records (EHR) or other relevant systems. Assist in tracking and organizing all documentation for utilization reviews, ensuring that all records are complete, accurate, and accessible for audits and reviews. Monitor the status of pending authorizations and document updates or changes to treatment plans in a timely manner. Assist in processing and reviewing requests for treatment authorization, working with clinicians to verify that all necessary documentation is available for review. Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies. Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews. Assist in preparing records and documentation for external audits or insurance company reviews, ensuring that all necessary information is submitted and compliant with guidelines. Identify any discrepancies, missing documentation, or areas where clinical records may require updates to meet the standards. Assist in coordinating with insurance providers to obtain authorization and resolve any issues related to service utilization or claims denials. Provide requested documentation and supporting materials for authorization and reauthorization requests, ensuring timely submission to insurance companies. Maintain records of communications with insurance companies, clinical teams, and other relevant stakeholders. Analyze trends in authorization requests, approvals, and denials and provide reports or insights to management to identify areas for process improvement. Track utilization patterns, service delivery, and compliance with payer requirements to support continuous improvement in the utilization review process. Communicate effectively with team members to ensure the smooth processing of treatment authorizations and timely updates on status or concerns. Provide clear communication regarding the status of clinical record reviews, authorization requests, and insurance queries. Participate in quality‑improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery. Qualifications Associate's or Bachelor’s degree in Healthcare Administration, Medical Records, Behavioral Health, or a related field. Certification in Health Information Management (e.g., RHIA, RHIT) is a plus but not required. Minimum of 1 year of experience working with clinical records, medical documentation, or utilization review, preferably in ABA therapy, behavioral health, or healthcare settings. Proven experience in utilization reviews or a related field with a strong understanding of healthcare service delivery and documentation processes is highly desirable. Must maintain clean background/drug screenings and driving record. Expertise Needed Familiarity with industry standards, guidelines, and best practices related to utilization review. Ability to analyze complex clinical documentation, treatment plans, and medical records. Strong critical thinking skills to assess the appropriateness and necessity of healthcare services. Strong analytical and critical thinking skills. Excellent communication and interpersonal skills. Benefits 21 paid days off (15 PTO days increasing with tenure, plus 6 paid holidays) Flexible Spending Account (FSA) and Health Savings Account (HSA) options Medical, dental, vision, long‑term disability, life insurance, AD&D insurance, and GAP Plan (TransAmerica) Generous 401(k) with up to 6% employer match 100% employer‑paid maternity/paternity leave for up to 5 weeks Tuition reimbursement up to $2,500 per semester EAP (unlimited counseling 24/7), BeyondMed (discounts on wellness and elective healthcare services), PerkSpot (discounts on top brands), Pet Insurance (Nationwide), and On the Go Gawellbeing hub Closing Statement Exact Billing Solutions is an Equal Opportunity Employer and is committed to building an inclusive workplace free from discrimination. We make employment decisions based on qualifications, merit, and business needs, and do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law. Exact Billing Solutions participates in the U.S. Department of Homeland Security E-Verify program. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the hiring process and employment. If you require assistance or accommodation, please let us know. #J-18808-Ljbffr