Manager of Utilization Review

Job Description

Job Description

Position Summary:

The Manager of Utilization Review (UR) is responsible for overseeing the day-to-day operations and strategic direction of the Utilization Review team within a Substance Use Disorder (SUD) treatment organization. This position ensures that all services provided meet medical necessity criteria, comply with regulatory and payer guidelines, and support timely, quality care for individuals undergoing treatment. The UR Manager serves as a key liaison between clinical teams, payers, and administrative departments to facilitate authorizations, continued stay reviews, and effective denial management.

Key Responsibilities:

• Lead, manage, and support the Utilization Review team, including hiring, training, scheduling, and performance evaluations.
• Oversee completion of initial and concurrent reviews to ensure timely submission to insurance companies and managed care organizations.
• Review clinical documentation to ensure it meets medical necessity for each level of care and is aligned with ASAM (American Society of Addiction Medicine) criteria.
• Collaborate with clinical and medical staff to ensure accurate, timely documentation that supports authorizations and treatment planning.
• Monitor and analyze UR metrics (e.g., authorization rates, denial trends, appeal outcomes) to improve processes and outcomes.
• Coordinate and oversee appeals for denied services, including reviewing clinical data and supporting documentation for accuracy.
• Ensure compliance with all state, federal, and accreditation regulations including HIPAA and Joint Commission or CARF standards.
• Act as a primary liaison with insurance companies, external reviewers, and third-party administrators.
• Stay updated on industry best practices and payer policy changes affecting SUD treatment and utilization review.
• Participate in audits, quality improvement initiatives, and cross-functional meetings as needed.
• Education & Licensure:
  • Bachelor’s degree in nursing, Social Work, Behavioral Health, or related field required.
  • Master’s degree preferred.
  • Active, unrestricted clinical license (e.g., RN, LCSW, LPC, LMFT) strongly preferred.

• Experience:

  • Minimum 3-5 years of Utilization Review experience in behavioral health or substance use disorder treatment setting.
  • At least 1-2 years of management or supervisory experience required.
  • In-depth knowledge of ASAM criteria and medical necessity determination.
  • Familiarity with various levels of care (detox, residential, PHP, IOP, OP) in SUD treatment.
  • Skills:
    • Excellent communication, organizational, and leadership skills.
    • Strong analytical skills and attention to detail.
    • Proficient in electronic health records (EHR) and UR platforms.
    • Ability to work collaboratively in a fast-paced, multidisciplinary environment.
    • Occasional travel to treatment sites or payer meetings may be required.