Utilization Review Case Manager

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At First Steps Recovery, we don’t just offer jobs — we offer purpose. As a leading, accredited behavioral health and substance use disorder treatment facility, our work changes lives daily. If you're driven by compassion, grounded in integrity, and thrive in a supportive, recovery-focused environment, you're exactly who we’re looking for.

When you join First Steps Recovery, you become part of a tight-knit, multidisciplinary team that values empathy, growth, and evidence-based care. Whether you’re working directly with clients or behind the scenes, every role here matters — and every day is an opportunity to make a difference.

Besides being an amazing company to work for, we also offer: 

· Medical, Dental, Vision benefits for full time employees

· PTO / Sick Leave Plans for full time and part time employees

· Free Employee Assistance Program for full time and part time employees

· Free Legal consultations and benefits for full time and part time employees

· Free Life Insurance for full time employees

· Generous 401K program for full time and part time employees

If you're ready to be part of something bigger, we invite you to take your next step with us! 

POSITION SUMMARY

The UR Case Manager serves as a liaison between clinical staff, the billing department, and third-party  payers to obtain and maintain treatment authorizations and advocate for continued care based on  client progress and medical necessity. This role requires strong clinical judgment, familiarity with SUD  treatment modalities, and proficiency in reviewing clinical documentation for accuracy and completeness. The position plays a vital role in supporting reimbursement processes, minimizing claim  denials, and ensuring quality client care across various levels of care, including detox, residential,  partial hospitalization, and intensive outpatient programs. 

Reasonable Accommodations Statement  To perform this job successfully, an individual must be able to perform each essential duty  satisfactorily. Reasonable Accommodations may be made to enable qualified individuals with  disabilities to perform the essential functions. 

Essential Functions 

1. Conduct Utilization Reviews 

• Perform initial, concurrent, and retrospective reviews using evidence-based criteria (e.g.,  ASAM, MCG, InterQual) to determine medical necessity and appropriate level of care. 

• Review benefit verifications to confirm that authorization requests are submitted to the  appropriate insurance company and department. 

• Review clinical documentation to evaluate patient needs and ensure completeness and  accuracy prior to submission to payers. 

• Collaborate closely with other First Step departments to resolve any insurance policy issues,  processes, or procedures that may hinder the ability to obtain authorization. 

• Escalate cases to insurance company UR managers when encountering opposition or obstacles  to ensure there are no gaps in coverage.

 2. Authorization Management 

• Submit timely and comprehensive authorization requests to insurance providers and managed  care organizations. 

• Call in precertification’s within 24 hours of each client’s admission or the next business day,  when applicable. 

• Participate in the on-call rotation every other weekend for inpatient admission notifications  required by certain insurance companies (after hours or on weekends). 

• Demonstrate an understanding of verification of benefits (VOB) and billing protocols to ensure  authorizations align with clean claim submission requirements. 

• Utilize the Kipu EMR system effectively, with a clear understanding of the integration between  UR and billing features. 

• Track and manage authorization approvals, denials, and expirations; ensure timely renewals to  prevent coverage gaps. 

• Coordinate with all relevant departments (e.g., admissions, clinical, medical, billing) to ensure  authorizations are correctly obtained, documented through the appropriate payer, and  accurately entered into the EMR system. 

• Manage authorization timelines, including start and stop dates, units, transitions such as step-ups and step-downs in the level of care, and cases that do not require authorization. 

3. Communication & Coordination 

• Communicate all authorization determinations to the inpatient and outpatient clinical  departments via the designated communication system. 

• Coordinate peer reviews and appeals for adverse determinations in collaboration with clinical  leadership. 

• Conduct and facilitate peer-to-peer reviews when needed. 

• Attend weekly interdisciplinary clinical meetings to stay updated on patient progress and  treatment planning. 

• Provide training and guidance on clinical documentation requirements to staff as needed. 

• Complete ad hoc projects related to the utilization review process as assigned by management. 

4. Documentation & Compliance 

• Maintain accurate, timely, and compliant documentation of all utilization review activities  within electronic health records (EHR) and payer portals. 

• Ensure all activities align with federal and state regulations, as well as accreditation standards  (e.g., Joint Commission, CARF). 

 Qualifications 

• Willing to work with multicultural populations and have an understanding of cultural diversity. 

• Previous experience in utilization review, case management, or healthcare administration. 

• Knowledge of behavioral health treatment modalities, insurance processes, and regulatory requirements. 

• Knowledge of health insurance plans and utilization management processes. 

• Proficiency in electronic health records (EHR) and utilization management software. 

• Strong communication, organizational, and critical thinking skills. 

• Ability to work independently and collaborate effectively with a multidisciplinary team. 

• Professional and courteous customer service skills both in person and over the phone. 

• HIPAA Certified. 

Experience 

• Two years of experience in a behavioral healthcare setting. 

• Experience in substance abuse treatment, dual diagnosis, or mental health treatment preferred. 

 Skills 

• Proficiency in medical necessity criteria (e.g., ASAM, InterQual, MCG) • Understanding of diagnoses, treatment plans, and levels of care • Insurance verification and authorization processes 

• Utilization management software  

• Electronic Health Record (EHR) systems navigation and documentation 

• Clear, professional communication with physicians, payers, and treatment teams 

• Effective phone and written communication with insurance companies for concurrent reviews 

• Advocacy for patient care needs while maintaining compliance with insurance criteria 

• Collaboration across interdisciplinary teams (clinical, billing, compliance) 

• Critical thinking and clinical judgment • Attention to detail in chart reviews and documentation 

• Prioritization and time management, especially under deadlines for insurance updates 

• Problem-solving, especially when handling denials or retroactive terminations 

• Knowledge of HIPAA, CMS, and state regulations 

• Familiarity with accreditation standards (e.g., The Joint Commission, CARF, URAC 

 Certificates & Licenses

• Must be willing to perform various tasks in the UR Department. 

• Professional and courteous customer service skills both in person and over the phone. 

• Drug and alcohol counseling credential or internship preferred. 

Other Requirements: 

• Medical Clearance to work  

• Ability to pass pre-employment drug screenings