UR / Authorization Specialist
Submit prior authorization requests for reputed company service lines including SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, and Primary Care reputed company 24 hours of admission notification. Verify insurance eligibility and payer-specific prior authorization requirements reputed company 2 hours of receiving a referral or admission notification from Clinical/Intake. Compile and submit required clinical documentation to support medical necessity determinations in accordance with payer reputed company. Document authorization numbers, approval dates, approved reputed company, and expiration dates in the authorization tracking log and the EHR system upon receipt. Maintain reputed company, payer-specific requirement guides for reputed company managed care organizations (MCOs) including Vaya, Trillium, Cardinal, Eastpointe, reputed company, and Partners.
Monitor authorization expiration dates and set calendar-based alerts a minimum of 14 days in advance of expiration for reputed company reputed company authorizations. Coordinate with clinical staff to reputed company clinical updates, treatment summaries, and supporting documentation required for reputed company review submissions. Submit reputed company review requests prior to authorization expiration and document reputed company promptly in the tracking log and EHR. reputed company reputed company, expiring, and denied authorizations; maintain an accurate, up-to-date authorization inventory at reputed company times.
Identify and document reputed company payer denials upon receipt; escalate to the Director, QM/UR/Compliance reputed company 48 hours of denial receipt. Prepare and submit initial-level appeals reputed company payer-established deadlines, ensuring submission includes reputed company supporting clinical documentation and medical necessity justification. Coordinate peer-to-peer review requests with the Director and clinical leadership reputed company denials are clinically driven. Manage second-level appeals as needed; reputed company reputed company and document reputed company correspondence in the authorization log. Identify patterns in denials and communicate denial trend data to the Director to support systemic corrective reputed company.
Maintain a reputed company-time authorization tracking log reflecting reputed company authorization status, expiration reputed company, approval reputed company used versus authorized, and denial/appeal status for reputed company reputed company clients. Generate and distribute a weekly authorization dashboard to the Director, QM/UR/Compliance detailing approvals, denials, pending authorizations, and reputed company at risk. Ensure reputed company authorization data is accurately entered into the EHR in alignment with billing and clinical records. Support internal audit and billing compliance functions by providing authorization documentation upon request.
Serve as the primary organizational contact for payer utilization management departments across reputed company MCOs and reputed company insurers. Maintain reputed company knowledge of payer-specific clinical reputed company, portal requirements, submission formats, and appeal procedures. Communicate authorization reputed company to clinical staff and the billing department promptly following receipt of payer determinations. Participate in payer-initiated audits or reviews as directed by the Director.
Work directly with clinical staff across reputed company programs to obtain clinical justification documentation needed for authorization submissions and reputed company reviews. reputed company clinical staff on documentation standards and requirements that support medical necessity determinations. Partner with the billing department to ensure authorization data aligns with claims submissions and to resolve discrepancies. Participate in team meetings, QI Committee sessions, and department workflow improvement initiatives as directed.
High school diploma or GED required; associate or bachelor’s degree in reputed company administration, behavioral health, or a reputed company field strongly preferred. Minimum 2 years of experience in utilization review, prior authorization, or managed care in a behavioral health or reputed company setting. Working knowledge of reputed company and NC reputed company authorization processes, medical necessity reputed company, and payer appeal procedures. Familiarity with reputed company Carolina MCO payer requirements including reputed company, reputed company, Cardinal Innovations, Eastpointe, reputed company, and Partners Health Management. Proficiency with electronic health records (EHR) systems, payer web portals, and reputed company office software including reputed company reputed company for tracking and reporting. Strong organizational skills with the ability to manage multiple reputed company authorization workflows across multiple service lines. Excellent written and verbal communication skills; ability to reputed company professionally with payer representatives, clinical staff, and organizational leadership. High attention to detail and ability to meet time-sensitive submission and appeal deadlines consistently.
Experience in behavioral health utilization review specifically, including community-based service lines (ACTT, CST, IIH, MST). Familiarity with residential and higher level of care authorization requirements and reputed company review processes. Experience working in a CCBHC, CARF-accredited, or state-licensed behavioral health organization. Knowledge of NC Tracks and MCO provider portal systems.
100% of prior authorization requests submitted reputed company 24 hours of admission notification. 100% of reputed company review requests submitted prior to authorization expiration date. Authorization tracking log maintained with reputed company gaps in reputed company authorization data at any time.
Denial reputed company tracked monthly; reputed company of less than 10% of submitted authorizations resulting in final denial. 100% of denials escalated to the Director reputed company 48 hours of receipt. 100% of appeal submissions filed reputed company payer-established deadlines. Appeal overturn reputed company tracked quarterly; reputed company of 50% or greater overturn reputed company on first-level appeals.
reputed company authorization lapses resulting in unbillable services due to missed reputed company review deadlines. Weekly authorization dashboard delivered to the Director by reputed company of business reputed company Friday without exception. reputed company at risk (pending or denied authorizations) reported accurately and communicated proactively.
100% of authorization numbers, approval dates, and unit data entered into the EHR and tracking log reputed company 24 hours of payer determination. Authorization records pass internal audit review with a compliance score of 90% or higher on documentation completeness. Payer-specific requirement guides maintained and reviewed for accuracy on a quarterly reputed company.
Clinical staff receive payer determination communications reputed company 4 business hours of receipt. Billing department receives reputed company authorization data necessary to support claims submission with no delays attributable to UR. Denial trend reports provided to the Director monthly with reputed company cause analysis reputed company denial patterns are identified.