Behavioral Health Authorizations Specialist

Prior Authorization

• Initiate, submit, and track prior authorization requests for all outpatient behavioral health services requiring payer approval across SCCS’s full payer mix.
• Verify that each PA request includes accurate and complete clinical and demographic information.
• Identify when supporting documentation is required and coordinate with clinical staff to obtain it within payer-required timeframes.
• Monitor all open authorization requests through payer portals and direct payer contact. Proactively follow up on pending requests before approval windows expire.
• Review all authorization denials promptly. Identify the denial reason, determine whether the denial is clinical, administrative, or procedural, and initiate the appropriate appeal pathway without delay.
• Document all authorization activity in MyEvolve/EHR at the time of each action, including submission date, payer, authorization number, approved CPT codes, session limits, expiration dates, denial reasons, and appeal outcomes.
• Support payer audits by ensuring authorization records are complete, current, and accessible.

Congurrent and Continued Stay Reviews

• Manage concurrent review and continued stay authorization requests for ongoing outpatient services.
• Track authorization session limits by payer and client, and initiate continued stay reviews before authorized sessions are exhausted to prevent gaps in care.
• Maintain a real-time tracking log of all active authorizations, including authorization numbers, session limits, expiration dates, and renewal status.
• Alert clinical and scheduling teams when sessions are running low or renewals are pending.

Denials and Appeals

• Review all authorization denials promptly. Identify the denial reason, determine whether the denial is clinical, administrative, or procedural, and initiate the appropriate appeal pathway without delay.
• Draft appeal letters that are precise, clinically grounded, and submitted within payer-required deadlines. Coordinate with clinicians to obtain supporting documentation.
• Track all appeals through resolution and document outcomes in the EHR and authorization log.
• Report recurring denial trends to the CMDO and flag systemic issues for escalation to the contracting or credentialing teams as appropriate.

Payer Coordination and Benefit Verification

• Verify insurance eligibility and benefits in real time for all clients requiring authorization before scheduling, using payer portals (Availity, Navinet, and payer-specific platforms) or direct payer contact.
• Confirm active coverage, plan type, deductible status, co-pay, out-of-pocket maximum, behavioral health carve-out provisions, and PA trigger thresholds.
• Proactively communicate payer changes to the intake and clinical teams.
• Communicate authorization status, session limits, and any payer-related barriers directly to intake staff and clinical supervisors.

Documentation and Reporting

• Document all authorization activity in MyEvolve/EHR at the time of each action, including submission date, payer, authorization number, approved CPT codes, session limits, expiration dates, denial reasons, and appeal outcomes.
• Produce regular authorization performance reports for the CMDO covering approval rates, denial rates, appeal win rates, average turnaround times, and outstanding requests by payer.
• Flag barriers and recommend process improvements based on data trends.

Payer Matrix, Process Documentation, and Training

• Own and maintain a current payer authorization matrix documenting PA requirements, submission workflows, portal access, turnaround standards, and session limits by payer and service type.
• Develop and maintain authorization process documentation and training materials for use by intake, scheduling, and clinical staff.

Expanded Payer Functions

• Manage commercial benefit verification for clients requiring authorization, coordinating with the Intake Specialist team to ensure eligibility and benefit information is complete before PA submission.
• Take on single-case agreement (SCA) coordination, out-of-network authorization requests, and proactive tracking of authorization requirements for new payer contracts as SCCS’s payer mix expands.

Cross-Team Support and Payer Audits

• Support the credentialing and contracting teams by identifying and escalating payer barriers, authorization delays, and denial trends that may indicate a broader contracting or network status issue.
• Participate in payer audits and utilization management reviews as requested, providing authorization records, data summaries, and supporting documentation.

Requirements

• In-depth knowledge of prior authorization (PA) requirements, timelines, and submission processes for behavioral health outpatient services across SCCS’s active payer mix.
• Strong working knowledge of the distinction between eligibility (active coverage), authorization (payer approval for a specific service), and medical necessity criteria as applied to behavioral health.
• Proficiency with payer portals including Availity, Navinet, and payer-specific platforms; experience navigating portal-based PA submission, status tracking, and documentation upload.
• Working knowledge of CPT codes relevant to behavioral health outpatient services and how payer authorization requirements vary by code across SCCS’s active and growing payer mix.
• Exceptional verbal and written communication skills; ability to interact professionally and persuasively with payer representatives, communicate authorization status clearly to clinical and intake staff, and draft appeal letters that are precise, evidence-based, and deadline-compliant.
• Knowledge of HIPAA Privacy and Security Rules and 42 CFR Part 2 confidentiality requirements. HIPAA certification required within 30 days of hire if not already held.
• Experience with utilization review processes, concurrent authorization requests, and continued stay reviews for outpatient behavioral health services.
• Familiarity with California-specific payer requirements, CalAIM’s impact on Medi-Cal managed care authorization rules, and IEHP and CalOptima plan structures.
• Bilingual fluency in English and Spanish strongly preferred given SCCS’s service population across San Bernardino and Orange Counties and beyond.
• Valid California driver’s license, proof of automobile insurance, and CPR/First Aid certification within 30 days of hire.