Utilization Review Specialist

Overview of the Position

• Job Title: Utilization Review Specialist
• Location: Glendale, AZ (Hybrid)
• Hours & Schedule: Full-Time
• Work Environment: Behavioral Health Treatment Facility (Hybrid – Remote & Onsite)
• Salary / Hourly Rate: $70,000 - $90,000 per year
• Benefits Offered:
• Medical, Dental, and Vision Insurance
• Paid Time Off (PTO) and Sick Leave
• 401(k) with Matching
• Tuition Reimbursement
• Gym Membership Reimbursement
• Yoga Membership
• Life Insurance
• Referral Program
• Health Savings Account (HSA)
• Professional Development Assistance

Company Introduction

We are a dedicated mental health and addiction treatment organization focused on helping adolescents and teens navigate their journey to recovery. Our comprehensive programs include residential care, outpatient treatment, therapy, and holistic approaches like art and music therapy to address mental health challenges such as depression, anxiety, PTSD, and substance use disorders.

Based in Arizona, we provide a safe, structured, and compassionate environment where young individuals can heal, develop essential life skills, and build a healthier future.

Why Work With Us?

We believe in making a real impact—our team is deeply committed to changing lives and fostering hope for young people in need.

What sets us apart:

• Supportive Work Culture – We invest in our team members and provide continuous support throughout the organization.
• Hybrid Work Model – Flexibility to work both remotely and onsite as needed.
• Outstanding Compensation & Benefits Package – Includes medical, dental, vision, PTO, 401(k) with match, tuition reimbursement, gym and yoga memberships, life insurance, professional development, and more.
• Strong Mission & Values – We are guided by a clear mission and core values that prioritize high-level care and real outcomes.

What Our Ideal New Team Member Looks Like

We are looking for individuals who embody the following qualities:

• Attention to Detail – Ensures accuracy in documentation and authorization processes.
• Connections and Strong Communication with Commercial Insurance – Knows how to navigate payer relationships and advocate for necessary services.
• Seasoned in Medical Necessity for Commercial Payers – Understands payer guidelines and documentation requirements to support approvals.
• Expertise in Single Case Agreements (SCAs) – Skilled in negotiating and managing SCAs for out-of-network services.
• Experienced in Continued Authorizations for Residential, PHP, and IOP Levels of Care – Proactively secures ongoing treatment approvals and prevents coverage gaps.

Job Summary

The Utilization Review Specialist is responsible for managing all aspects of the utilization review process, including preauthorization, Single Case Agreements (SCAs), continued authorizations, and clinical documentation compliance. This role plays a crucial part in securing necessary authorizations for various levels of care, advocating for clients with insurance providers, and supporting the clinical team by ensuring documentation aligns with medical necessity criteria.

The Utilization Review Specialist works closely with insurance providers, clinical staff, and leadership to facilitate smooth authorization processes and prevent disruptions in client care.

Job Duties & Responsibilities

Preauthorization

• Manage and submit preauthorization requests to insurance providers for clients entering treatment at Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Standard Outpatient (OP) levels of care.
• Ensure all required documentation accurately reflects the clinical needs of the client.
• Communicate with insurance companies to secure timely approvals for necessary services.

Single Case Agreements (SCAs)

• Negotiate and manage Single Case Agreements with insurance providers for clients needing services outside of network coverage.
• Ensure all SCAs are documented, approved, and communicated to the relevant clinical and billing teams.

Continued Authorizations

• Monitor ongoing treatment needs and submit continued authorization requests for Residential, PHP, IOP, and OP levels of care to ensure uninterrupted client care.
• Work closely with clinical staff to gather necessary documentation, including progress notes and updated treatment plans to support authorization requests.
• Track authorization deadlines and proactively follow up to prevent lapses in coverage.

Clinical Staff Collaboration

• Attend regular meetings with clinical staff to discuss client progress, treatment plans, and authorization needs.
• Provide feedback on documentation practices and suggest improvements to align with insurance requirements.

Training and Education

• Develop and deliver training sessions for clinical staff on medical necessity criteria and documentation standards required by insurance providers.
• Create resources and guidelines for clinicians to reference when documenting client care and treatment progress.
• Offer ongoing support and education to ensure all clinical documentation consistently meets the standards required for successful authorization.

Client Advocacy

• Serve as a liaison between clients, clinical teams, and insurance providers to advocate for necessary care.
• Manage and appeal authorization denials, providing additional documentation or clarification as needed.

Compliance and Reporting

• Ensure all utilization review activities comply with relevant regulations, insurance policies, and organizational standards.
• Maintain detailed records of all authorization requests, approvals, and communications with insurance providers.
• Generate reports on authorization success rates, SCA outcomes, and areas for improvement in the utilization review process.

Prerequisites / License & Certification Requirements

• Experience: At least 3-5 years of experience in utilization review, medical billing, or a related field, preferably in a behavioral health setting.
• Required Expertise:
• Established relationships and communication skills with commercial insurance payers.
• Strong knowledge of medical necessity guidelines for commercial payers.
• Proven experience managing and negotiating Single Case Agreements (SCAs).
• Expertise in continued authorization processes for Residential, PHP, and IOP levels of care.
• Education: Bachelor’s degree in Healthcare Administration, Social Work, or a related field preferred.
• Skills:
• Strong understanding of insurance authorization processes, including preauthorization, continued authorization, SCAs, and multiple levels of care.
• Excellent communication and negotiation skills with the ability to advocate effectively for client needs.
• Proficiency in electronic medical records (EMR) systems and documentation standards.
• Ability to collaborate with clinical staff and provide training on complex topics in a clear and supportive manner.
• Detail-oriented with strong organizational and time-management skills.

If you meet these qualifications and are passionate about ensuring clients receive the care they need, we encourage you to apply.

Apply today with your updated Resume/CV. Cover letters and references are preferred but optional. We look forward to meeting you.

Requirements

• Experience: At least 3-5 years of experience in utilization review, medical billing, or a related field, preferably in a behavioral health setting.
• Required Expertise:
• Established relationships and communication skills with commercial insurance payers.
• Strong knowledge of medical necessity guidelines for commercial payers.
• Proven experience managing and negotiating Single Case Agreements (SCAs).
• Expertise in continued authorization processes for Residential, PHP, and IOP levels of care.
• Education: Bachelor’s degree in Healthcare Administration, Social Work, or a related field preferred.
• Skills:
• Strong understanding of insurance authorization processes, including preauthorization, continued authorization, SCAs, and multiple levels of care.
• Excellent communication and negotiation skills with the ability to advocate effectively for client needs.
• Proficiency in electronic medical records (EMR) systems and documentation standards.
• Ability to collaborate with clinical staff and provide training on complex topics in a clear and supportive manner.

Detail-oriented with strong organizational and time-management skills.

Benefits

• Salary / Hourly Rate: $70,000 - $90,000 per year
• Benefits Offered:
• Medical, Dental, and Vision Insurance
• Paid Time Off (PTO) and Sick Leave
• 401(k) with Matching
• Tuition Reimbursement
• Gym Membership Reimbursement
• Yoga Membership
• Life Insurance
• Referral Program
• Health Savings Account (HSA)
• Professional Development Assistance