About Us – Mission & Values
At All In Solutions, our mission is to provide quality, evidence-based treatment that leads to long-term recovery for every client who walks through our doors. We believe that connection and purpose are essential to this pursuit, guiding every decision we make and every service we provide.
Position Summary
The Utilization Review Specialist is a critical, hands-on role responsible for ensuring all client admissions, continued stays, and services meet the criteria for clinical necessity and adhere to payer requirements and state/federal regulations. This role directly executes the Utilization Review process to secure authorizations, minimize denials, and maintain compliance standards across our behavioral health and substance use disorder (SUD) programs.
Responsibilities
- Conduct and submit timely and accurate pre-certifications, concurrent reviews, and continued stay authorizations for clients across all levels of care (Detox, Residential, PHP, IOP).
- Proficiently utilize and document against established medical necessity criteria, including ASAM Criteria, LOCUS, and InterQual, to support clinical justification for treatment.
- Prepare and submit clear, clinically sound documentation for the initial stages of denial appeal and grievance processes.
- Maintain detailed and organized UR documentation within the Electronic Medical Record (EMR), ensuring all records are audit-ready and compliant with internal and external standards.
- Serve as a knowledgeable and professional point of contact for routine communications with payer representatives (insurance companies) regarding authorization requests and follow-up.
- Collaborate with the UR Manager and clinical team to ensure documentation supports full compliance with state licensing regulations (NJ DOH, FL DCF, CA DHCS) and accreditation standards (CARF/Joint Commission).
- Maintain current knowledge of relevant changes to payer guidelines, medical necessity criteria, and state/federal regulations that impact UR processes.
