Utilization Review Specialist

Kids Thrive - Utilization Review (UR) Specialist Position Summary The Utilization Review (UR) Specialist plays a critical role in ensuring that all Kids Thrive clients receive timely, appropriate, and authorized care. This position oversees the authorization lifecycle for all new and existing clients, verifies accuracy of clinical and billing information, and serves as the primary liaison between Kids Thrive, insurance payers, and the multidisciplinary clinical team. The UR Specialist ensures compliance with payer requirements, maintains accurate documentation, and supports efficient revenue cycle operations. Key Responsibilities1. Admission & Authorization Management Monitor all new admissions to ensure client demographic, clinical, and insurance information is complete and accurate in the billing system. Obtain prior authorizations for services, including initial reviews, concurrent reviews, and reauthorization requests. Communicate directly with insurance companies, managed care organizations, and other payers to secure authorization for all levels of care provided by Kids Thrive. 2. Clinical Coordination & Documentation Review Collaborate with the multidisciplinary team (therapists, case managers, medical providers, etc.) to gather necessary clinical documentation for authorization requests. Review clinical reports, treatment plans, progress notes, and assessments to articulate the medical necessity of services. Ensure all documentation submitted to payers meets regulatory and payer‑specific standards. 3. Tracking, Reporting & Compliance Maintain accurate and up‑to‑date authorization logs , including start/end dates, units approved, and payer requirements. Track and manage single case agreements , ensuring terms are documented and communicated to internal teams. Maintain denial logs , assist with denial prevention strategies, and support appeals when appropriate. Monitor authorization expirations and proactively request renewals to prevent service disruption. 4. Billing Coordination Work closely with the corporate billing department to ensure all authorizations, payer updates, and documentation requirements are reflected accurately in the billing system. Communicate changes in payer requirements, authorization status, or client coverage to billing and clinical teams. Support resolution of billing discrepancies related to authorization or payer issues. 5. Communication & Stakeholder Support Serve as a knowledgeable resource for staff regarding payer policies, authorization processes, and documentation expectations. Provide timely updates to clinical teams, leadership, and families regarding authorization status and payer decisions. Ensure Kids Thrive remains responsive to the needs of clients, payers, and internal departments. Qualifications Experience in utilization review , case management , billing , or insurance authorization within behavioral health, pediatrics, or healthcare preferred. Strong understanding of payer requirements, medical necessity criteria, and clinical documentation standards. Excellent communication skills, both written and verbal. High attention to detail, strong organizational skills, and the ability to manage multiple priorities. Proficiency with electronic health records (EHR) and billing systems.

Pay:

$60,000.00 - $75,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Employee assistance program Health insurance Life insurance Paid time off Professional development assistance Tuition reimbursement Vision insurance

Work Location:

In person