The Utilization Review (UR) Manager is responsible for overseeing utilization management operations across Detox, Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Outpatient (OP) levels of care. This position provides leadership and oversight of the organization's authorization, concurrent review, continued-stay, peer-to-peer, denial, reconsideration, and appeals processes. The UR Manager works closely with Clinical, Nursing, Admissions, Billing, Revenue Cycle, Compliance, and Executive Leadership to ensure that services are supported by appropriate clinical documentation, medical necessity criteria, and payer requirements. The UR Manager plays a critical role in maintaining timely authorizations, minimizing avoidable denials and uncovered days, supporting appropriate patient transitions, and protecting organizational reimbursement. Key Responsibilities Lead and oversee daily Utilization Review/Utilization Management operations , establishing standardized workflows, productivity expectations, quality-monitoring processes, and escalation procedures. Manage initial, concurrent, continued-stay, and retrospective reviews , ensuring authorization dates, approved days/units, review deadlines, and payer-specific requirements are accurately tracked and addressed. Ensure clinical documentation appropriately supports diagnoses, ASAM criteria, medical necessity, treatment plans, clinical risk, functional impairment, interventions, progress, and discharge barriers . Coordinate payer communications, including authorization requests, clinical reviews, peer-to-peer discussions, reconsiderations, and appeals , while maintaining current knowledge of payer-specific requirements and processes. Monitor patients and cases at risk for non-authorization, denials, uncovered days, or administrative discharge , and collaborate with the treatment team to facilitate timely clinical interventions and discharge planning. Partner closely with Nursing, Providers, Therapists, Case Management, Admissions, Billing, Compliance, Revenue Cycle, and Executive Leadership to ensure alignment between clinical documentation, authorization requirements, patient care, and financial outcomes. Review payer and denial data to identify trends, recurring documentation deficiencies, authorization barriers, and opportunities for improvement. Develop and implement corrective action plans designed to reduce preventable denials, authorization delays, uncovered days, and reimbursement-related revenue leakage. Maintain accurate and timely UR records and ensure all authorization activity is appropriately documented within the designated EHR and utilization management systems. Participate actively as a member of the interdisciplinary treatment team , including attendance at clinical and utilization review meetings. Provide education and training to clinical and operational staff regarding medical necessity, payer requirements, documentation standards, authorization processes, and denial prevention . Establish and monitor UR performance metrics, including authorization turnaround times, denial rates, appeal outcomes, productivity, and other key performance indicators. Maintain current knowledge of behavioral health utilization management practices, payer policies, ASAM criteria, regulatory requirements, and industry standards . Escalate complex authorization, clinical, compliance, or reimbursement concerns to appropriate leadership in a timely manner. Promote a culture of accountability, collaboration, clinical integrity, compliance, and continuous improvement within the utilization management function. Qualifications & Preferred Experience Bachelor's degree in Nursing, Healthcare Administration, Behavioral Health, Social Work, or a related field preferred. Active RN, LCSW, LMHC, or comparable professional licensure/credential preferred. Minimum of 3-5 years of experience in behavioral health utilization review/utilization management, case management, payer relations, clinical operations, or a related field. Previous supervisory or management experience preferred. Strong knowledge of behavioral health levels of care, including Detox, Residential, PHP, IOP, and OP . Strong working knowledge of ASAM criteria, medical necessity standards, clinical documentation requirements, and utilization management practices . Demonstrated understanding of commercial insurance, Marketplace plans, and government payer requirements . Experience with Substance Use Disorder (SUD) treatment and behavioral health services strongly preferred. Experience working with payers such as BCBS, UnitedHealthcare, Cigna/Evernorth, Aetna, and Marketplace plans preferred. Demonstrated experience conducting or coordinating peer-to-peer reviews, reconsiderations, denial management, and appeals . Experience with EHR and utilization management platforms required; Kipu and CollabMD experience preferred . Strong analytical, organizational, communication, problem-solving, and leadership skills. Ability to manage multiple priorities, meet time-sensitive payer deadlines, and work effectively in a fast-paced behavioral health environment.

Core Competencies Utilization Management & Medical Necessity Behavioral Health & SUD Knowledge Payer Relations & Authorization Management Denial Prevention & Appeals Clinical Documentation Review Revenue Protection & Reimbursement Leadership & Team Development Data Analysis & Performance Improvement Cross-Departmental Collaboration Compliance & Regulatory Awareness Pay:

$70,000.00 - $90,000.00 per year

Benefits:

Dental insurance Health insurance Paid time off Vision insurance

Work Location:

Hybrid remote in Vero Beach, FL 32963