Utilization Review Specialist

Bradford Health Services

. Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows .

Posted 9/19/2026full-timeRemote • Alabama • United StatesJuniorMid-Level💰 $60,000 - $75,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Review processes, including insurance authorization, clinical documentation interpretation, and compliance with regulatory standards. Proficient in managing caseloads, communicating effectively with stakeholders, and ensuring adherence to payer requirements.

Highest-signal resume keywords

Utilization ReviewInsurance AuthorizationBehavioral Health ExperienceClinical Documentation InterpretationHIPAA Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

PrecertificationConcurrent ReviewAuthorization TrackingCase ManagementPayer Follow-UpASAM Criteria KnowledgeClinical Appeals PreparationRetrospective ReviewsQuality AuditsRoot-Cause Analysis

Soft Skills

Strong Verbal CommunicationWritten CommunicationAttention to DetailProfessional JudgmentCommitment to Patient Confidentiality

Tools & Technologies

Electronic Medical Record SystemsPayer PortalsMicrosoft Office Applications

Certifications & Qualifications

Active Clinical LicenseRelevant Certification

Industry Keywords

Behavioral HealthcareSubstance Use Disorder TreatmentManaged CareRevenue CycleMedicareMedicaidTRICAREVeterans Affairs

About the role

Key responsibilities & impact

Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows
Obtain, document, and monitor authorizations across the continuum of care
Review medical records and collaborate with treatment teams to obtain complete clinical information supporting medical necessity and requested levels of care
Present clinical information clearly and persuasively to payer representatives using medical-necessity criteria and payer guidelines
Maintain authorization records in electronic medical records, payer portals, tracking systems, and other applications
Monitor caseloads and authorization deadlines daily; complete follow-up and escalate unresolved barriers
Identify clinical documentation gaps or inconsistencies and communicate needs to clinicians, providers, or leaders
Coordinate with clinical and case-management teams on transitions, discharge planning, and level-of-care changes
Escalate adverse determinations requiring peer-to-peer review, reconsideration, appeal, or leadership intervention
Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations
Review payer correspondence and adverse determinations, communicate outcomes, and complete follow-up
Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives
Follow utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states
Maintain knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and service-line requirements
Collaborate with Utilization Review leadership, admissions, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners
Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies
Perform other duties as assigned in support of Utilization Review and Revenue Cycle objectives

Requirements

What you’ll need

High school diploma or equivalent required
Minimum 2 years of experience in behavioral healthcare, substance use disorder treatment, utilization review, managed care, insurance authorization, case management, revenue cycle, or a closely related function
Behavioral Health and/or Substance Use Disorder experience required
Working knowledge of insurance authorization processes, including precertification, concurrent review, continued-stay review, authorization tracking, and payer follow-up
Ability to interpret clinical documentation and communicate symptoms, functional impairment, risk factors, treatment needs, progress, and barriers to discharge
Ability to manage multiple cases, payer deadlines, and competing priorities with accuracy and appropriate escalation
Strong verbal and written communication skills, professional judgment, attention to detail, and commitment to patient confidentiality
Working knowledge of HIPAA and 42 CFR Part 2 requirements
Relevant college coursework, professional certification, or equivalent directly related experience strongly preferred
Bachelor's degree in a related healthcare discipline preferred
Knowledge of ASAM Criteria and behavioral health levels of care preferred
Experience with commercial insurance, Medicare, Medicaid, Managed Medicaid, TRICARE, Veterans Affairs, or other managed-care payers preferred
Experience preparing cases for peer-to-peer reviews, reconsiderations, retrospective reviews, and clinical appeals preferred
Active clinical license or relevant certification preferred but not required
Experience with enterprise electronic medical record systems, payer portals, and Microsoft Office applications preferred

Benefits

Comp & perks

Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits
Expanded Coverage – Options for domestic partners and a wider network of in-network providers
Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching
Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more
Student Loan Repayment – Available for nurses and therapists
Retirement Benefits – 401(k) plan through Voya
Generous PTO – A robust paid time off policy
Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week
Great Place to Work® Certification
Supportive and rewarding workplace