Utilization Review Specialist

Job Description

Utilization Review Specialist – Behavioral Health

Location: Philadelphia, PA

Facility: The Behavioral Wellness Center at Girard

Schedule: Full-Time Exempt Day Shift

Company Overview:

The Behavioral Wellness Center at Girard is a well-established behavioral health facility in Philadelphia providing inpatient and outpatient psychiatric and substance abuse treatment. As a leader in behavioral healthcare, we are committed to offering evidence-based services that are culturally and spiritually responsive to the needs of our diverse community.

Our services include:

Substance Use Disorder Services

Inpatient Psychiatric Services

Outpatient Drug & Alcohol Treatment Services

We strive to enhance the competency and abilities of our staff through innovative training and development initiatives.

Position Summary:

The Utilization Review Specialist is responsible for managing all utilization review activities, including admissions, continued stay reviews, discharge planning, and payer communication. This role ensures medical necessity, secures authorizations, and supports reimbursement processes while working closely with clinical teams and managed care organizations.

Responsibilities:

Conduct admission, concurrent, and focused reviews using ASAM criteria

Maintain accurate and timely documentation of utilization review activities

Perform retrospective reviews and support third-party payer audits

Identify and report utilization trends and potential issues to leadership

Collaborate directly with physicians, providers, and managed care organizations

Manage the appeal process for denials and monitor outcomes

Provide ongoing training to staff on documentation standards and medical necessity

Prepare and submit monthly utilization review reports and statistics

Coordinate findings with the business office to resolve payment issues

Conduct quality reviews and facilitate peer review calls

Act as the liaison between the clinical team and managed care organizations

Qualifications:

Bachelor’s degree or higher in Mental Health, Human Services, Social Services, or a related field

Minimum two (2) years of clinical experience in behavioral health or psychiatric care

Prior utilization review experience required

ASAM certification and/or clinical licensure preferred (LPC, CADC, CAADC, etc.)

Knowledge of PA WITS program and Electronic Health Records

Strong organizational, communication, and interpersonal skills

Ability to prioritize, meet deadlines, and maintain confidentiality

Physical Requirements & Work Environment:

Ability to communicate effectively in person and by phone

Manual dexterity for data entry and documentation

Ability to sit for extended periods; occasional lifting up to 10 lbs.

Work in office and clinical settings with potential exposure to environmental hazards.

We are an Equal Opportunity Employer EOE/M/F/D/V

Full-time