Utilization Review

Job Details: Job Location: Corporate HQ - QUINCY, MA, Salary Range: $50000.00 - $95000.00Salary/year, Our mission. Northeast Recovery is a network of Substance Use Disorder Treatment & Behavioral Health Treatment Facilities that provide a variety of levels of care to those who are prepared to begin their journey toward recovery and Salary: $50,000 – $95,000 per year (based on experience and applicable licensure) Overview A Utilization Review professional reviews patient cases, medical records, and treatment plans to determine whether healthcare services meet established guidelines for necessity, efficiency, and quality.    Key Responsibilities Review patient medical records for medical necessity and appropriateness of care Apply standardized criteria such as InterQual or MCG (Milliman Care Guidelines) as well as understand the ASAM 3rd and 4th Edition Criteria and stay abreast of industry changes. Approve, deny, or recommend modifications to treatments or stays Communicate with physicians, nurses, and case managers regarding care decisions Ensure compliance with insurance policies and regulatory requirements Document review findings and decisions thoroughly Participate in discharge planning and care coordination Identify opportunities to reduce unnecessary costs while maintaining quality care    Required Skills Strong knowledge of insurance, levels of care and the MH/SUD industry treatment models. Critical thinking and analytical skills Attention to detail Knowledge of healthcare regulations and insurance policies Communication and negotiation skills Familiarity with electronic medical records (EMR systems) Solid understanding of HIPPA Ability to work independently with minimal supervision and manage time effectively in a fast-paced environment Excellent written and verbal communication skills required. TEAM SPIRIT – We are a support department.  We support our patients, our facility staff and each other.    Technical Skills Requirement Proficient in basic computer operations, including the use of internet-based fax and phone systems Ability to efficiently navigate multiple insurance portals and electronic systems Comfortable working with web-based applications, email, and electronic documentation tools    Education & Requirements For Utilization Review Nurse: Active RN license (required) Bachelor of Science in Nursing (BSN) often preferred Clinical experience (usually 2–5 years) For Non-Clinical UR Specialist: Degree in healthcare administration or related field or verifiable work experience in the MH/SUD utilization review capacity of 2 years or more preferred but not required. Experience in medical coding, billing, or case management helpful  Work Settings Remote/work-from-home position Must maintain high speed internet capable of running Internet Phone and Fax Software. Must be able to sit for extended periods of time.     Certifications (Optional but Valuable) Certified Professional in Healthcare Quality (CPHQ) Certified Case Manager (CCM) Utilization Review Accreditation   Why Work for Us! We provide an environment where our employees can grow and advance professionally, with a healthy balance between work and personal lives. Our biggest investment is in our employees, so we reward and recognize hard work by promoting from within when possible. We pay competitively and offer a variety of benefits to meet your wellness and financial needs. EEO and Accommodations We are deeply committed to building a workplace and community where inclusion is not only valued but prioritized. We're proud to be an equal opportunity employer, seeking to create a welcoming and diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, family status, marital status, sexual orientation, national origin, genetics, neurodiversity, disability, age, or veteran status, or any other non-merit based or legally protected grounds. We are committed to providing reasonable accommodation to qualified individuals with disabilities in the employment application process. To request accommodation, please contact Human Resources at least one week in advance of your interview. Qualifications: For Utilization Review Nurse: Active RN license (required) Bachelor of Science in Nursing (BSN) often preferred Clinical experience (usually 2–5 years) For Non-Clinical UR Specialist: Degree in healthcare administration or related field or verifiable work experience in the MH/SUD utilization review capacity of 2 years or more preferred but not required. Experience in medical coding, billing, or case management helpful  Work Settings Remote/work-from-home position Must maintain high speed internet capable of running Internet Phone and Fax Software. Must be able to sit for extended periods of time.