Utilization Review Representative (Behavioral Health / SUD & MH) – Remote (U.S.)

Overview We are seeking a dedicated and detail-oriented Utilization Review Representative specializing in Behavioral Health, Substance Use Disorder (SUD), and Mental Health (MH) to join our remote team. This role is essential in ensuring that patient care is aligned with clinical guidelines and that services provided are medically necessary. The ideal candidate will possess a strong background in utilization management, clinical documentation improvement, and familiarity with various coding systems. Responsibilities • Conduct thorough reviews of clinical documentation to determine the medical necessity of services rendered. • Collaborate with healthcare providers to gather necessary information for utilization review. • Ensure compliance with NCQA standards and HIPAA regulations throughout the review process. • Utilize EMR and EHR systems effectively to document findings and maintain accurate records. • Engage in discharge planning and case management to facilitate patient transitions. • Analyze data related to patient care and outcomes to identify areas for improvement. • Provide support in the development of clinical guidelines and protocols for utilization management. • Maintain up-to-date knowledge of medical terminology, coding (CPT, ICD-9, ICD-10), and healthcare regulations. Skills • Proficiency in Epic, Cerner, Athenahealth, eClinicalWorks, or similar EMR/EHR systems. • Strong understanding of managed care principles and acute care settings. • Experience in critical care, ICU, or emergency medicine preferred. • Knowledge of medical documentation practices, including DRG and MDS coding. • Familiarity with home care services and hospice care processes. • Excellent analytical skills with a focus on clinical documentation improvement. • Strong communication skills for effective collaboration with healthcare teams. • Ability to work independently while managing multiple priorities in a remote environment. This position is an excellent opportunity for professionals looking to leverage their clinical expertise in a remote setting while making a significant impact on patient care quality. Job Type: Full-time Pay: $57,000.00 - $63,000.00 per year Benefits: • Health insurance • Paid time off Work Location: Remote