Full-time Utilization Review Specialist

St. Joseph's Addiction Treatment and Recovery Centers

Location: Inpatient Facility - Saranac Lake, NY

Position: Full-time Utilization Review Specialist

Shift/schedule: Monday-Friday, 8:00am-4:30pm

Pay Range: $22.00/hour to $28.60/hour

Position Summary: This role works collaboratively with clients, admissions, finance, medical departments, and insurance companies to support the admission process and ensure continued authorization for treatment across multiple program types. The position requires a strong understanding of Medicaid, managed care, and private insurance, which include insurance verification, pre-certification, and concurrent reviews. Candidates should have familiarity with medical and psychiatric diagnoses, screening tools and medications. A working knowledge of insurance practices, strong attention to detail, excellent organizational skills, and the ability to multitask in a fast-paced environment are essential.

Education and Training: Associate degree in behavioral health discipline and/or equivalent experience.

Qualifications and Requirements: Minimum two (2) years in a healthcare setting. Must be computer literate with strong proficiency in Microsoft applications, and knowledgeable of clinical documentation systems. ability to make appropriate decisions based on insurance requirements and SJRC policy, as evidenced by meeting standards on performance appraisal. Obtain CAC (Certified Application Counselor) credentials within the first 6 months of employment.

Essential Duties:

• Collect and review client information from admissions and clinical departments, ensuring accuracy and compliance in documentation, and providing targeted feedback for continuous improvement.
• Review funding prior to admission to ensure all appropriate documentation is presented.
• Assess patient documentation to confirm medical necessity, utilizing provided tools, enhancing treatment authorization success.
• Communicate clinical information to insurance company reviewers to obtain treatment authorizations and continued stay approvals.
• Coordinate the exchange of required documentation between providers, staff, and insurance companies.
• Work with the medical providers and clinicians to facilitate insurance reviews as needed to address initial denials and appeals.
• Prepare and submit written summaries following insurance reviews.
• Maintain CAC credentials and assist clients with obtaining insurance coverage and recertifications.
• Bi-Monthly insurance verifications on all in-house clients.
• Maintain, report and manage all Inpatient client account cards for internal spending accounts.
• Prepare financial statements for discharge and coordinate account card reimbursements, if necessary.
• Support behavioral utilization activities, aligning with agency policies to promote optimal client care and cost-effective outcomes.
• Ensure all processes align with State, Federal, CARF standards, and agency policies, maintaining adherence to the highest standards.
• Pursue ongoing education to remain updated on managed care, healthcare regulations, and case management best practices.
• Contribute to quality assurance activities, working on improvement initiatives that elevate clinical and operational standards.
• Perform other duties as directed by Supervisor, supporting the agency’s mission and client care quality.