Utilization Review Specialist | Davao

Req ID: 4891
Connext is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Utilization Review Specialist who will be working with Connext's Client in the United States of America.

What's in it for you?

• 25% Night Differential
• Perfect Attendance Bonus
• Mid-year Bonus!
• Competitive compensation
• Life insurance
• HMO Insurance
• Great company culture

What is the job?

The Utilization Review Specialist is responsible for managing insurance utilization reviews, prior authorizations, and clinical documentation reviews to support timely access to care.

Responsibilities:

• Review clinical records to assess medical necessity and ensure compliance with payer guidelines.
• Conduct utilization reviews and obtain prior authorizations and continued stay approvals.
• Coordinate with providers and insurance carriers to secure timely authorizations and documentation.
• Monitor authorization status, resolve discrepancies, and support appeals for denied services.
• Maintain accurate utilization review records, reports, and payer communications.
• Ensure compliance with HIPAA, regulatory requirements, and utilization management standards.

Qualifications:

• Minimum of one (1) year of experience in utilization review, utilization management, prior authorization, medical review, or healthcare operations.

• Experience supporting behavioral health, mental health, or substance use disorder treatment services, including PHP, IOP, OP, or facility-based healthcare billing environments.

• Has knowledge in payer requirements, medical necessity guidelines, and healthcare compliance standards.

• Hands-on experience using ASAM Criteria and LOCUS/CALOCUS.

• Proven ability to review clinical information and determine documentation completeness.