Utilization Review Specialist

Description

POSITION SUMMARY

The Utilization Review Specialist is responsible for ensuring clinical services are medically necessary, appropriately authorized, and compliant with applicable New York State Office of Addiction Services and Supports (OASAS) regulations, Medicaid Managed Care requirements, and third-party payer guidelines. RECAP currently operates two New York State OASAS-certified substance use disorder treatment programs: a Part 820 Residential Reintegration Program and a Part 822 Outpatient Rehabilitation Program. The Utilization Review Specialist provides utilization management and clinical documentation review services across both programs. The position works collaboratively with clinical staff, program leadership, billing personnel, managed care organizations, insurance representatives, and other stakeholders to support appropriate service authorization, documentation compliance, quality improvement, and effective reimbursement.

ESSENTIAL FUNCTIONS

Utilization Management Obtain initial service authorizations prior to admission when required by Medicaid Managed Care Organizations and commercial insurance plans. Complete concurrent reviews and continued-stay reviews within required payer timelines. Submit clinical documentation supporting medical necessity for requested services. Monitor authorization expiration dates and take appropriate action to support uninterrupted coverage. Coordinate peer-to-peer reviews when requested by insurance carriers. Prepare and submit reconsiderations and appeals for denied or reduced services. Maintain accurate authorization tracking logs and records. Monitor authorization outcomes and payer decisions. Notify appropriate clinical staff of authorization approvals, denials, limitations, and other payer determinations. Ensure utilization review activities are completed in accordance with payer requirements and applicable regulatory standards. Clinical Documentation Review Review clinical assessments, treatment plans, progress notes, multidisciplinary documentation, toxicology results, discharge planning documentation, and medical records for completeness and compliance. Ensure clinical documentation supports applicable ASAM Criteria dimensions and level-of-care determinations. Verify that documentation supports medical necessity for ongoing treatment. Identify documentation deficiencies and communicate recommendations to clinical staff. Assist clinicians in strengthening documentation to meet payer and regulatory expectations. Monitor completion of required clinical documentation within established regulatory and payer timeframes. Identify trends in clinical documentation that may impact authorizations, compliance, quality, or reimbursement. Provide guidance and education to clinical staff regarding documentation requirements and best practices. Revenue Cycle Support Collaborate with billing staff to ensure services are appropriately authorized prior to claim submission. Investigate authorization discrepancies that may affect reimbursement. Identify and address issues that may result in avoidable claim denials. Assist with resolving payer documentation requests. Monitor payer trends and identify opportunities to improve authorization processes and reimbursement. Maintain current knowledge of payer-specific authorization and documentation requirements. Communicate authorization-related concerns to appropriate program and fiscal staff. Quality Improvement Conduct routine clinical chart audits to evaluate documentation quality and compliance. Monitor documentation quality indicators and identify opportunities for improvement. Participate in Quality Improvement (QI) and Performance Improvement (PI) committees and initiatives. Assist with the development and implementation of corrective action plans. Identify trends related to denials, documentation deficiencies, authorization issues, and compliance concerns. Provide education and feedback to staff regarding clinical documentation and utilization management best practices. Support ongoing efforts to improve clinical service quality, regulatory compliance, and client outcomes. Collaboration and Communication Attend multidisciplinary treatment team meetings as assigned. Collaborate with physicians, nurse practitioners, counselors, nursing staff, care coordinators, program leadership, billing personnel, and administration. Serve as a resource to clinical and administrative staff regarding payer requirements, utilization management, and medical necessity criteria. Communicate effectively with managed care organizations, insurance representatives, referral sources, and other external stakeholders. Facilitate communication between clinical, administrative, and fiscal teams regarding authorization and documentation matters. Escalate complex or unresolved utilization concerns to the Senior Director of Addictions. Administrative Responsibilities Maintain accurate utilization review records and documentation. Track authorization requests, approvals, denials, appeals, and payer decisions. Generate utilization review reports and other reports requested by agency leadership. Maintain accurate and organized authorization tracking systems. Monitor payer requirements and communicate significant changes to appropriate staff. Maintain confidentiality of all client and agency information in accordance with HIPAA, 42 CFR Part 2, applicable laws, and RECAP policies. Participate in staff meetings, training, and professional development activities as required. Perform other duties and responsibilities as assigned by the Senior Director of Addictions.

COMPLIANCE RESPONSIBILITIES

Ensure utilization review activities comply with applicable federal, state, and local laws and regulations. Maintain compliance with applicable NYS OASAS requirements. Maintain compliance with Medicaid Managed Care and commercial payer requirements. Ensure clinical documentation supports medical necessity and applicable level-of-care criteria. Maintain confidentiality of protected health information and substance use disorder treatment records in accordance with HIPAA and 42 CFR Part 2. Maintain accurate, complete, and timely utilization review documentation. Participate in internal audits, quality improvement activities, and compliance reviews as assigned. Remain current with changes to applicable regulations, payer requirements, utilization management practices, and clinical documentation standards. Report potential compliance concerns to the Senior Director of Addictions and appropriate agency leadership.

BEHAVIORAL EXPECTATIONS

Employees are expected to: Demonstrate professionalism, integrity, accountability, and dependability. Maintain confidentiality at all times. Exercise sound judgment and discretion when handling sensitive clinical and financial information. Communicate respectfully and effectively with clients, employees, supervisors, clinical professionals, payers, and external partners. Work collaboratively as part of a multidisciplinary team. Demonstrate strong attention to detail and commitment to accuracy. Meet established deadlines and payer requirements. Demonstrate initiative and follow-through. Maintain appropriate professional boundaries. Adapt to changing payer requirements, regulatory expectations, and organizational priorities. Support RECAP's mission, values, and commitment to providing quality services to the communities it serves.

WORK ENVIRONMENT

Work is performed primarily in office and clinical treatment environments. The position requires frequent interaction with clinical staff, agency leadership, insurance representatives, managed care organizations, referral sources, and other external partners. The position may require occasional schedule flexibility to meet payer deadlines, authorization requirements, clinical review timelines, or other program needs. Employees are expected to follow all applicable safety procedures, agency policies, HIPAA requirements, 42 CFR Part 2 requirements, and regulatory standards while performing job duties.

REASONABLE ACCOMMODATION

RECAP is committed to providing reasonable accommodation to qualified individuals with disabilities in accordance with the Americans with Disabilities Act (ADA) and applicable state and local laws. Reasonable accommodations may be made to enable qualified individuals to perform the essential functions of this position unless doing so would impose an undue hardship on the organization.

EQUAL EMPLOYMENT OPPORTUNITY

RECAP is an Equal Opportunity / Afffigative Action Employer. We are committed to fostering a diverse and inclusive workplace and prohibit discrimination and harassment based on race, color, creed, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, veteran status, or any other characteristic protected by applicable federal, state, or local law.

DISCLAIMER

This job description describes the general nature and level of work expected of the position. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or working conditions. RECAP reserves the right to modify, assign, or remove duties and responsibilities as organizational, programmatic, or operational needs require. Requirements Required 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 another Qualified Health Professional (QHP) recognized by NYS OASAS. Minimum of three (3) years of experience in behavioral health or substance use disorder treatment. Minimum of two (2) years of utilization review, case management, quality improvement, or managed care experience preferred. Experience working in an OASAS-certified program strongly preferred. Experience working with Medicaid Managed Care and commercial insurance plans required. Knowledge of ASAM Criteria required. Knowledge of OASAS regulations and applicable behavioral health requirements. Strong written, verbal, analytical, and interpersonal communication skills. Strong organizational and time-management skills with the ability to manage multiple deadlines. Strong attention to detail and ability to review complex clinical documentation. Ability to identify documentation deficiencies and communicate recommendations effectively. Ability to work collaboratively with multidisciplinary teams. Ability to maintain strict confidentiality and exercise sound judgment and discretion. Proficiency with Microsoft Office applications and electronic health records or other applicable database systems. Ability to work independently while also functioning effectively as part of a team. Ability to travel between RECAP locations as required.

PHYSICAL REQUIREMENTS

Ability to sit for prolonged periods while performing computer-based and documentation-related duties. Ability to use computers, telephones, printers, copiers, and other standard office equipment. Ability to review electronic and paper documentation for extended periods. Ability to communicate effectively in person, by telephone, and electronically. Occasional lifting of up to 20 pounds. Ability to travel between RECAP locations as required. Consistent punctuality and attendance at the assigned worksite are required.

ADDITIONAL EMPLOYMENT REQUIREMENTS

Must maintain all required professional licenses, credentials, certifications, and registrations necessary to perform the duties of the position. Must maintain credentials in good standing and complete required renewals within applicable deadlines. Must successfully complete required pre-employment background screening and receive satisfactory results in accordance with RECAP policies and applicable requirements. Must successfully complete the required pre-employment drug screening and receive satisfactory results in accordance with RECAP policies and applicable requirements. Must successfully complete any required physical examination or health clearance. Must maintain reliable attendance and punctuality. Must complete required agency, program, compliance, and departmental training. Must comply with all RECAP policies, procedures, program requirements, and applicable laws and regulations. Must comply with applicable HIPAA, 42 CFR Part 2, OASAS, Medicaid Managed Care, and payer confidentiality and documentation requirements. Must maintain confidentiality of client, employee, financial, clinical, and organizational information. Must exercise appropriate discretion when handling protected health information and other sensitive information. Must maintain proficiency with required electronic health records, databases, Microsoft Office applications, and other systems necessary to perform assigned duties. Must successfully complete any required agency-specific training, credentialing, or payer-related requirements. Must perform other job-related duties as assigned. #J-18808-Ljbffr Regional Economic Community Action Program, Inc.