A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
High school diploma or GED required. An Associate's or Bachelor's is strongly preferred.
Experience:
1-3 years of experience in prior authorization, medical billing, utilization review (UR), or patient access within a behavioral health or addiction treatment setting. Specialized SUD & Mental Health Knowledge Behavioral health payers rely on precise criteria to approve levels of care.
Candidates generally must demonstrate:
ASAM Criteria Knowledge:
Understanding of the American Society of Addiction Medicine (ASAM) criteria across dimensions (e.g., Level 3.5 Residential vs. Level 2.1 IOP) to support medical necessity for SUD treatment.
Diagnostic & Clinical Terminology:
Familiarity with
DSM-5 / ICD-10
coding, medical terminology, and psychiatric terminology (e.g., detox protocols, dual diagnosis, PHP, IOP, outpatient).
Parity & Regulatory Awareness:
Basic understanding of the Mental Health Parity and Addiction Equity Act (MHPAEA), HIPAA compliance, and state-specific behavioral health regulations.
Payer-Specific Guidelines:
Familiarity with commercial insurance (e.g., Optum, Beacon/Carelon, BCBS) and Medicaid/Medicare utilization guidelines for mental health and addiction services.
Technical & Software Skills EHR/EMR Systems:
Hands-on experience with Carelogic.
Payer Portals:
Proficiency navigating web portals (e.g., Availity, NaviNet, Provider Express) to submit authorizations, check concurrent review statuses, and track approvals.
Data Management:
Proficiency with Microsoft Excel/Google Sheets for tracking authorization lifecycles, expiration dates, and authorized unit counts.
Core Core Competencies Clinical Translation:
Ability to read therapist notes, biopsychosocial assessments, and nursing documentation, extracting key risk factors (e.g., SI/HI, withdrawal symptoms, relapse risk) to present to insurance medical directors.
Urgency & Time Management:
Ability to manage tight turnaround windows for emergency or acute admissions (e.g., detox or inpatient stabilization requests often require submission within 24 hours of admission).
Appeal & Peer-to-Peer Coordination:
Experience handling initial denial appeals, gathering peer-to-peer review documentation, and coordinating physician-to-doctor discussions. Attention to
Detail:
Precision in matching authorized billing codes (CPT/HCPCS) with authorized dates of service to prevent revenue cycle rejections.
