Utilization Management Specialist

Essential Functions

• Serve as an internal resource regarding insurance coverage, authorizations, and utilization management requirements
• Cook with Managed Care Organizations (MCOs), commercial insurance companies, and other payors regarding treatment authorizations and continued stay reviews
• Support timely submission of clinical and administrative documentation to maintain authorization compliance
• Aid in denial management activities, including scheduling peer-to-peer reviews and facilitating communication between providers and payors
• Maintain authorization status and communicate updates to appropriate team members

Revenue Cycle Support

• Coordinate insurance verification, authorization tracking, claims submission, and payment posting within the electronic health record (EHR) system
• Monitor claims, denials, payment variances, and reimbursement trends
• Identify and resolve issues contributing to payment delays, denials, or revenue cycle inefficiencies
• Collaborate with internal teams and external partners to support efficient reimbursement processes
• Ensure billing and documentation processes comply with regulatory, organizational, and payor requirements

Provider Credentialing & Compliance

• Cook with provider credentialing, recredentialing, and enrollment activities
• Monitor provider licensure, DEA renewals, and related credentialing requirements
• Maintain accurate credentialing and compliance records

Operational Support & Team Collaboration

• Train and support staff on insurance, authorization, and billing workflows
• Provide backup support for referral coordination and front desk operations as needed
• Maintain accurate and timely documentation related to insurance and billing coordination
• Participate in meetings, trainings, and quality improvement initiatives
• Communicate professionally with residents, families, payors, and community partners

Qualifications

• Minimum of three (3) years of experience in: Utilization management, Insurance authorization, Medical billing, Revenue cycle operations, Provider credentialing, Healthcare administration or related healthcare operations
• Knowledge Of Utilization management processes, Insurance authorization requirements, Claims submission and payment posting, Revenue cycle operations
• Experience in a healthcare environment, preferably in a behavioral health setting