Utilization Review Specialist

1 week ago

Boynton Beach, Florida, United States All In Solutions Full time $40,000 - $90,000 per year
Job Details Boynton Beach - Boynton Beach, FL Optional Work from Home High School $ $ Salary/year Day Description

About Us – Mission & Values

At All In Solutions, our mission is to provide quality, evidence-based treatment that leads to long-term recovery for every client who walks through our doors. We believe that connection and purpose are essential to this pursuit, guiding every decision we make and every service we provide.

Position Summary

The Utilization Review Specialist is a critical, hands-on role responsible for ensuring all client admissions, continued stays, and services meet the criteria for clinical necessity and adhere to payer requirements and state/federal regulations. This role directly executes the Utilization Review process to secure authorizations, minimize denials, and maintain compliance standards across our behavioral health and substance use disorder (SUD) programs.

Responsibilities

  • Conduct and submit timely and accurate pre-certifications, concurrent reviews, and continued stay authorizations for clients across all levels of care (Detox, Residential, PHP, IOP).
  • Proficiently utilize and document against established medical necessity criteria, including ASAM Criteria, LOCUS, and InterQual, to support clinical justification for treatment.
  • Prepare and submit clear, clinically sound documentation for the initial stages of denial appeal and grievance processes.
  • Maintain detailed and organized UR documentation within the Electronic Medical Record (EMR), ensuring all records are audit-ready and compliant with internal and external standards.
  • Serve as a knowledgeable and professional point of contact for routine communications with payer representatives (insurance companies) regarding authorization requests and follow-up.
  • Collaborate with the UR Manager and clinical team to ensure documentation supports full compliance with state licensing regulations (NJ DOH, FL DCF, CA DHCS) and accreditation standards (CARF/Joint Commission).
  • Maintain current knowledge of relevant changes to payer guidelines, medical necessity criteria, and state/federal regulations that impact UR processes.

Your skills. Our mission. A brighter future for recovery. Ready to use your expertise to clear the path for life-changing recovery? Join our growing team. Apply now and be ALL IN 

Qualifications

Qualifications

  • Bachelor's degree in Healthcare Administration, Social Work, Nursing, Psychology, or a related field strongly preferred (or equivalent professional experience).
  • Minimum of 2 years of proven, hands-on utilization review or case management experience in an inpatient behavioral health or SUD setting.
  • Direct experience and proficiency in applying ASAM Criteria for patient placement and continued stay justification.
  • Demonstrated ability to write clear, compelling clinical justifications for review submissions.
  • Proficiency with Kipu EMR systems and general UR tracking/submission tools is highly preferred.

Key Compliance Competencies

  • Practical working knowledge of one or more of the following state-specific licensure regulations and documentation requirements for SUD facilities:NJ: NJAC Title 10:161A & 10:161B, FL: Florida Administrative Code Chapter 65D-30, CA: Title 9 CCR, Chapter 11
  • Familiarity with the Utilization Review processes for Medicaid, Medicare, and commercial payers in a multi-state setting.
  • A meticulous and detail-oriented approach to maintaining UR files and documentation to ensure audit readiness for payers and state licensing bodies.

Ready to use your expertise to clear the path for life-changing recovery? Apply now and be ALL IN.

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