Job Description – Utilization Specialist (Contractor)
Company: Wise Path Recovery Centers (in partnership with Ascension Recovery Services)
Location: Remote – must reside in Eastern or Central Time Zone
General Description
The Utilization Specialist supports the authorization and utilization management (UM) process for patients receiving treatment across Wise Path Recovery Centers’ West Virginia programs. This role ensures accurate and timely payer authorizations at admission, during treatment, and at discharge, while maintaining compliance with federal and state (WVDHHR) requirements. The Utilization Specialist works closely with clinical staff, payors, and billing partners to support patient access to care and minimize denial risk.
Essential Duties
- Perform and document initial certification, concurrent reviews, and discharge reviews within required timeframes.
- Submit clinical information to payors to support admission, continued stay, and discharge decisions.
- Obtain authorization numbers and maintain current, accurate records in designated systems.
- Verify active authorizations, in-network vs. out-of-network benefits, and communicate coverage details to patients and teams.
- Serve as a liaison with billing/vendor partners to ensure authorization details align with claim submission.
- Escalate barriers to authorization requiring clinical expertise and assist in coordinating peer-to-peer reviews.
- Track, trend, and report denials or authorization challenges; recommend process improvements.
- Adhere to West Virginia-specific payer requirements and DHHR regulations.
- Protect patient confidentiality at all times in accordance with HIPAA.
- Support the organization’s mission and core values of integrity, respect, teamwork, and excellence.
Qualifications
- Bachelor’s degree preferred; 3+ years of relevant experience may substitute.
- Registered Nurse, Licensed Social Worker, or other licensed behavioral health clinician preferred.
- At least 2 years’ experience in utilization review, case management, or discharge planning.
- Experience in behavioral health and/or substance use disorder treatment across multiple levels of care required (detox, residential, PHP, IOP).
- Familiarity with West Virginia Medicaid and commercial payor requirements strongly preferred.
- Strong communication and documentation skills with ability to present clinical information to payors.
- Proficiency with EMRs and payer portals.
Key Competencies
- Attention to Detail: Maintains accurate, complete, and compliant records.
- Communication: Conveys clinical and coverage information effectively to payors, patients, and care teams.
- Collaboration: Works seamlessly with clinical, billing, and administrative staff.
- Problem Solving: Identifies and escalates authorization barriers proactively.
- Integrity & Confidentiality: Protects patient information and adheres to legal/ethical standards.
- Regulatory Knowledge: Applies knowledge of payer requirements, HIPAA, 42 CFR Part 2, and WVDHHR standards.
Work Conditions
- Remote position; must be based in Eastern or Central Time Zone.
- Standard business hours with flexibility for payor deadlines.
- Primarily computer- and phone-based role.
- Occasional extended hours may be required to meet authorization requirements.
Performance Expectations
- Meet required payer timeframes for initial, concurrent, and discharge reviews.
- Maintain accurate authorization records with zero tolerance for errors that may delay claims.
- Demonstrate effective collaboration with clinical and billing teams.
- Uphold confidentiality and compliance standards without exception.
- Contribute to a culture of quality improvement and excellence in patient care access.
Equal Employment Opportunity Statement
Wise Path Recovery Centers, in partnership with Ascension Recovery Services, provides equal employment opportunities to all employees and applicants. We comply with all federal, state, and local employment laws and prohibit discrimination or harassment based on race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other protected status.