Utilization Review Specialist

6 hours ago

Cebu City, Central Visayas, Philippines RemoteRaven Full time ₱1,200,000 - ₱2,400,000 per year

UTILIZATION REVIEW SPECIALIST – REMOTE (FULL TIME)


About the Role

We are hiring a Utilization Review Specialist to manage all aspects of insurance authorization, ensuring timely approvals, accurate documentation, and effective collaboration with clinical teams. This role plays a key part in advocating for clients and supporting continued care across multiple treatment levels.


Key Responsibilities

Preauthorization

  • Submit authorization requests for multiple levels of care (residential, PHP, IOP, OP).
  • Ensure documentation accurately reflects clinical needs.
  • Communicate with insurance providers for timely approvals.

Single Case Agreements (SCAs)

  • Negotiate and manage SCAs.
  • Ensure details are documented and shared with relevant teams.

Continued Authorizations

  • Submit ongoing authorization requests to avoid treatment interruptions.
  • Work closely with clinical staff to compile required documentation.
  • Track and follow up on deadlines to prevent lapses.
  • Maximize authorization length through effective case presentation.

Collaboration With Clinical Staff

  • Participate in regular case-review meetings.
  • Provide feedback to improve documentation aligned with insurance standards.

Training and Education

  • Conduct training for clinicians on medical necessity and documentation standards.
  • Develop reference resources to support consistent compliance.

Client Advocacy

  • Act as a liaison between clinical teams, clients, and insurance providers.
  • Appeal denials with supporting documentation when necessary.

Compliance and Reporting

  • Maintain accurate records of authorization requests and outcomes.
  • Ensure all processes comply with regulatory and policy requirements.
  • Generate periodic reports for performance tracking and improvement.

Minimum Qualifications
  • Bachelor's degree in healthcare administration, social work, or a related field preferred.
  • 3–5 years of experience in utilization review, medical billing, or a similar field, ideally within behavioral health.
  • Strong understanding of insurance authorization processes including preauth, continued auth, SCAs, and multiple treatment levels.
  • Excellent communication, negotiation, and client advocacy skills.
  • Proficient in EMR systems and clinical documentation standards.
  • Highly organized with strong time-management skills.

Working Conditions
  • Remote role with standard office equipment required.
  • May occasionally require weekend or evening availability depending on caseload and operational needs.

Employment Type
  • Full Time
  • Remote
  • Competitive compensation package

How to Apply

Send your resume to:

Email Subject Line:

Jobstreet Applicant | Utilization Review Specialist | Complete Name

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