Remote: Utilization Review Specialist

About the role

As a Utilization Review Specialist at Alsana, you will support utilization management activities including medical necessity reviews, clinical documentation, and patient status determination. You will work closely with clinical teams and leadership to help ensure appropriate levels of care, accurate documentation, and compliance with payer and regulatory requirements.

Responsibilities

• Perform utilization review, including pre-authorization, concurrent, and retrospective reviews for inpatient and/or outpatient services.
• Maintain current knowledge of payer requirements, LOCUS criteria, regulatory standards, accreditation expectations, and evidence-based documentation practices.
• Use clinical expertise and payer knowledge to act as a liaison to treatment team members through ongoing communication.
• Attend weekly Treatment Team Meetings, providing updates on new authorizations and at-risk cases.
• Maintain timely, accurate records of review determinations, information requests, and recommendations within the electronic medical record (EMR).
• Inspect documentation to confirm compliance with payer requirements, regulatory standards, accreditation expectations, and evidence-based documentation practices.
• Assist with appeals, denials management, and corrective actions related to utilization review findings.
• Participate in case conferences and provide training and education related to documentation standards and utilization review.

Qualifications

• One or more of the following credentials: LPC, LCSW, LMFT, RD, RN, LVN, LPN, or PsyD
• Experience in utilization review or case management preferred
• Experience in a business/corporate setting or similar environment preferred
• Experience in eating disorders preferred

Benefits

• Medical, Dental, and Vision insurance with multiple plan options (Cigna nationwide; Kaiser available in CA)
• HSA plans with employer contributions
• FSA Healthcare and Dependent Care plan options
• Generous PTO, sick time, Covid Time, and 6 paid holidays
• Company-paid Basic Life and AD&D insurance
• Short-term disability (company-paid for non-CA; CA uses state plan)
• Continuing education stipend for eligible roles
• Voluntary benefits including Supplemental Life, Long-Term Disability, Accident, and Hospital Indemnity
• LifeMart employee discount program