Utilization Review Specialist

Job Description

Title: Billing Utilization Specialist (Substance Use and Mental Health Services)

General Purpose:

Make sure services provided (like therapy, IOP, detox, MAT, etc.) are properly documented, billed, and reimbursed.

Review clinical documentation to ensure it matches insurance requirements.

Maximize reimbursement while staying fully compliant with healthcare laws and payer contracts.

Key Responsibilities:

Utilization Review: Check that services are medically necessary and authorized by insurance.

Billing Coordination: Submit claims, correct billing errors, follow up on denied claims.

Documentation Support: Help clinicians document services in a way that meets insurance and accreditation standards.

Compliance Monitoring: Stay up-to-date with Medicaid, Medicare, and private insurance rules.

Authorization Management: Track and request pre-authorizations and continued stay authorizations.

Reporting: Create utilization reports for leadership, showing trends, billing patterns, or problem areas.

Skills Needed:

Strong knowledge of ICD-10, CPT coding, and payer requirements (especially Medicaid/Medicare).

Experience with behavioral health EMRs (like Kareo, Kipu, SimplePractice, or similar).

Attention to detail and organizational skills.

Ability to work closely with clinical and administrative staff.Company Description

At Tribe Recovery Services, we are committed to helping individuals achieve lasting recovery through compassionate care, evidence-based practices, and a supportive community. We are looking for an Assistant Clinical Director who shares our passion and is ready to help lead our clinical team to the next level.

Full-time