Utilization Review Specialist

Description

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.

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.

• 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 time frames.
• 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.

• 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.

• 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…