Prior Authorization Specialist

About the role

The Prior Authorization Specialist serves as the lead staff member for prior authorizations within Integrated Services for Behavioral Health. This role supports timely access to behavioral health and substance use treatment services by coordinating insurance approvals, resolving coverage barriers, monitoring authorization requirements, and collaborating closely with clinical, intake, billing, and care coordination teams.

Responsibilities

• Serve as the lead staff member for prior authorizations within Integrated Services for Behavioral Health
• Support timely access to behavioral health and substance use treatment services by coordinating insurance approvals, resolving coverage barriers, monitoring authorization requirements, and collaborating with clinical, intake, billing, and care coordination teams
• Lead the prior authorization process for outpatient behavioral health, substance use disorder, intensive outpatient, and other covered services, including submissions, extensions, and continued stay reviews
• Coordinate with providers and clinical teams to obtain and submit required documentation supporting medical necessity and authorization requests
• Maintain compliance with HIPAA, mandated reporting requirements, and professional ethical guidelines
• Monitor authorization timelines, approved units, and expiration dates to prevent service interruptions and potential denied claims
• Communicate authorization approvals, denials, and follow-up needs to clinical, billing, and operational staff
• Afford assistance with appeals, reconsiderations, peer reviews, and the resolution of denied or delayed services
• Verify insurance eligibility, behavioral health benefits, and service coverage across Medicaid, managed care, commercial insurance, and OhioRISE plans
• Support coordination of coverage changes, payer transitions, Medicaid enrollment issues, and secondary insurance concerns
• Serve as a liaison between clinical staff, billing teams, insurance companies, and external partners regarding authorization and coverage issues
• Develop and improve workflows, tracking systems, and communication processes related to authorizations and insurance navigation
• Monitor authorization trends, payer requirements, denials, and operational barriers while participating in interdisciplinary meetings and process improvement initiatives
• Utilize databases and Electronic Health Record systems for accurate client information retrieval
• Manage multiple priorities and maintain attention to detail in a fast-paced environment
• Operate in an Internet-based, automated office environment
• Maintain a high-speed internet connection

Requirements

• A high school diploma or GED is required
• An associate's or bachelor's degree in human services, social work, or a related field is preferred
• 2 years of experience in healthcare, behavioral health, or a related field is preferred
• 2 years of experience working with prior authorization, insurance verification, behavioral health operations, medical billing, utilization review, or healthcare navigation is preferred
• Experience working within community mental health, substance use treatment, healthcare, or social service settings is preferred

Qualifications

• Advanced communication skills, both oral and written
• Advanced organizational skills
• Problem-solving and customer service skills
• The ability to maintain confidential information
• Knowledge of Medicaid, managed care, commercial insurance, OhioRISE, waiver services, and behavioral health authorization processes
• The ability to manage multiple priorities and maintain attention to detail in a fast-paced environment
• Proficiency with electronic health records and Microsoft Office applications
• The ability to manage deadlines within a fast-paced, high-volume environment
• The ability to operate in an Internet-based, automated office environment
• The ability to maintain a high-speed internet connection

Skills

• Advanced communication skills, both oral and written
• Advanced organizational skills
• Problem-solving and customer service skills
• The ability to maintain confidential information
• Knowledge of Medicaid, managed care, commercial insurance, OhioRISE, waiver services, and behavioral health authorization processes
• The ability to manage multiple priorities and maintain attention to detail in a fast-paced environment
• Proficiency with electronic health records and Microsoft Office applications
• The ability to manage deadlines within a fast-paced, high-volume environment
• The ability to operate in an Internet-based, automated office environment
• The ability to maintain a high-speed internet connection

Benefits

• Medical
• Dental
• Vision
• Short-term Disability
• Long-term Disability
• 401K w/ Employer Match
• Employee Assistance Program (EAP)