Breva Systems, SA de CV · 1 month ago
Utilization Review Manager
Chicago, IL
Full-time
Onsite
Mid, Senior Level
3+ years expBreva Systems, SA de CV is a mental healthcare provider specializing in trauma recovery services. The Utilization Review Manager is responsible for coordinating clinical documentation and service authorizations to ensure medical necessity and regulatory compliance while acting as a liaison between clinical staff and payers.
Information TechnologyIT ManagementSecurity
Responsibilities
Conduct ongoing utilization reviews of client treatment plans, progress notes, and service delivery to ensure alignment with payer and regulatory requirements
Coordinate with insurance companies by submitting all required documentation and addressing any disputes or discrepancies
Submit, track, and follow up on initial and continued service authorization requests with insurance carriers and funding sources
Monitor and analyze denial trends, proactively identifying opportunities to improve documentation and authorization processes
Maintain detailed records of authorization status, denials, and appeal outcomes
Collaborate with clinicians to ensure treatment plans, assessments, and progress notes meet clinical and payer criteria
Provide guidance and training to staff on documentation standards related to utilization review and medical necessity
Participate in internal audits and assist in developing corrective action plans when deficiencies are identified
Serve as the primary point of contact for payer representatives regarding authorizations, reauthorizations, and claims-related issues
Partner with the revenue cycle team to reconcile service utilization against approved authorizations
Work closely with Clinical Operations and Counseling supervisors to monitor caseload utilization and prevent service gaps or overages
Ensure adherence to HIPAA, Medicaid, and managed care regulations
Maintain up-to-date knowledge of payer requirements, industry standards, and policy changes affecting utilization management
Prepare and present utilization and authorization reports to leadership, identifying patterns and recommendations for improvement
Qualification
Required
Masters degree in Nursing, Psychology, Social Work, Health Administration, or related field required
Minimum 3–5 years of utilization review, case management, or clinical documentation experience in a healthcare, behavioral health, or managed care environment
Strong knowledge of insurance authorization processes and payer criteria
Excellent analytical and communication skills
High attention to detail and ability to manage multiple cases simultaneously
Proficiency in EHR systems and Google Office Suite
Preferred
Active LCSW or LCPC clinical licensure highly preferred
Benefits
Competitive salary and benefits package.
A supportive and dynamic work environment committed to social impact.
Opportunities for professional development and growth.
Company
Breva Systems, SA de CV
Breva Systems, Inc.
11-50 employees
Funding
Current Stage
Early StageCompany data provided by crunchbase