Utilization Review Specialist

Join a mission-driven organization dedicated to providing high-quality, person-centered care for individuals with substance use disorders. The agency operates two New York State OASAS-certified programs: a Part 820 Residential Reintegration Program and a Part 822 Outpatient Rehabilitation Program. As a Utilization Review Specialist, you will play a vital role in ensuring that clinical services are medically necessary, appropriately authorized, and compliant with all regulatory and payer requirements. This position offers the opportunity to collaborate with a multidisciplinary team, support quality improvement initiatives, and help maximize access to care for those in need. Responsibilities Obtain initial, concurrent, and continued stay authorizations from Medicaid Managed Care Organizations and commercial insurance plans. Conduct comprehensive reviews of clinical documentation to ensure compliance with medical necessity, ASAM Criteria, and OASAS regulations. Monitor authorization expiration dates and ensure uninterrupted coverage for clients. Coordinate peer-to-peer reviews, reconsiderations, and appeals for denied or reduced services. Maintain accurate authorization tracking logs and document all utilization review activities in the electronic health record. Collaborate with clinical, medical, and administrative staff to ensure treatment plans and documentation support payer requirements and regulatory standards. Assist clinicians in strengthening documentation and provide feedback on best practices. Participate in internal quality assurance, utilization review, and quality improvement initiatives. Support revenue cycle management by ensuring services are properly authorized and investigating discrepancies affecting reimbursement. Attend multidisciplinary team meetings and serve as a resource on payer requirements and medical necessity criteria. Assist with regulatory readiness, including preparation for OASAS certification reviews and audits. Maintain confidentiality in accordance with HIPAA and 42 CFR Part 2. Perform additional duties as assigned. Qualifications Bachelor's degree in Social Work, Psychology, Human Services, Nursing, or a related behavioral health field required; Master's degree preferred. One of the following credentials required: LMSW, LCSW, LMHC, CASAC, CASAC-AC, CASAC-MC, RN, or other qualified health professional recognized by NYS OASAS. Minimum of three years of experience in behavioral health or substance use disorder treatment. At least two years of experience in utilization review, case management, quality improvement, or managed care preferred. Experience working in an OASAS-certified program strongly preferred. Experience with Medicaid Managed Care and commercial insurance plans required. Knowledge of ASAM Criteria required. Strong clinical assessment and documentation review skills. Excellent written and verbal communication skills. Ability to analyze clinical documentation for regulatory compliance. Strong organizational and time management skills, with the ability to prioritize multiple deadlines. Proficiency in electronic health records and Microsoft Office applications. Ability to sit for prolonged periods and use computers and office equipment; occasional lifting up to 20 pounds. Ability to travel between agency locations as required. #J-18808-Ljbffr Air Comfort, Inc