UTILIZATION REVIEW:

• Conduct regular reviews of clinical documentation to ensure compliance with payer requirements and medical necessity criteria (e.g., ASAM, MCG, InterQual).
• Submit initial and concurrent insurance authorizations for residential, PHP, and IOP levels of care.
• Communicate with insurance case managers and update them on client progress.
• Maintain accurate records of authorizations, denials, and appeals.
• Collaborate with clinicians and medical providers to gather necessary clinical updates.

QUALIFICATIONS:

• Bachelor’s degree in Healthcare Administration, Business, Nursing, or related field (required).
• Minimum 5 years of experience in utilization review, medical billing, or revenue cycle management, with at least 2 years in a supervisory/management role.
• Strong knowledge of payer guidelines, insurance authorizations, and healthcare billing regulations.
• Familiarity with electronic health record (EHR) and billing systems.
• Excellent leadership, organizational, and communication skills.
• Ability to analyze data, identify trends, and implement process improvements.
• Proficient in Electronic Medical Records (EMR) systems

ESSENTIAL FUNCTIONS:

The UR and Billing Manager is responsible for overseeing all aspects of utilization review, medical billing, and reimbursement functions for the organization. This role ensures compliance with payer requirements, accurate and timely claim submission, and effective coordination between clinical, billing, and administrative teams. The manager will lead efforts to maximize reimbursement, monitor denials, and improve revenue cycle processes, while also guiding staff in day-to-day operations.

PHYSICAL REQUIREMENTS: The physical demands outlined below represent those necessary for an employee to successfully perform the essential functions of this role:

• Regularly required to sit, use hands for handling or feeling, and communicate effectively through speech and hearing.
• Frequently required to reach with hands and arms.
• Occasionally required to stand and walk.
• Specific vision requirements include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
• This role involves light physical demands