Utilization Review Specialist

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Full Time Office/Clerical Remote, Birmingham, AL, US

14 days ago Requisition

Salary Range: $60,000.00 To $75,000.00 Annually

Bradford Health Services provides addiction treatment programs, resources, and community for every aspect of recovery. Through our premier drug and alcohol rehab facilities across the Southeast, we provide affordable, evidence-based addiction treatment with proven outcomes at every level of care. We’re guided by unity and dedicated to meeting and treating every patient right where they are. Bradford is more than a healthcare network;

we are recovery communities for every stage of the journey.

We are seeking a Utilization Review Specialist to add to our dynamic team! The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes.

By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews in accordance with payer requirements and established departmental workflows
• Obtain, document, and monitor authorizations across the continuum of care, including approved level of care, number of units or days, effective dates, review dates, authorization numbers, and payer‑specific conditions
• Review the medical record and collaborate with the treatment team to obtain complete, accurate, and timely clinical information supporting medical necessity and the requested level of care
• Present clinical information to payer representatives clearly, objectively, and persuasively, using applicable medical‑necessity criteria and payer guidelines
• Maintain accurate authorization records in the electronic medical record, payer portals, tracking systems, and other designated applications
• Monitor assigned caseloads and authorization deadlines daily; complete required follow‑up and elevate unresolved payer, documentation, or authorization barriers before reimbursement is placed at risk
• Identify clinical documentation gaps or inconsistencies and communicate specific needs to the appropriate clinician, provider, or leader without directing clinical care or altering the clinical record
• Coordinate with clinical and case‑management teams regarding anticipated transitions, discharge planning, and changes in level of care to support continuity of treatment and timely payer notification
• Recognize potential adverse determinations and promptly elevate cases requiring peer‑to‑peer review, reconsideration, appeal, or leadership intervention
• Prepare concise case summaries and supporting documentation for peer reviews, appeals, and other payer escalation activities as assigned
• Review payer correspondence and adverse determinations for accuracy, communicate outcomes to appropriate stakeholders, and complete required follow‑up within established deadlines
• Participate in denial review, root‑cause analysis, quality audits, training, and performance‑improvement initiatives
• Follow…