About This Role
This specialist role focuses on obtaining and maintaining insurance authorizations for clients receiving substance use disorder treatment. It involves close collaboration with clinical staff, admissions, and insurance companies to ensure accurate medical necessity documentation and timely authorizations, maximizing reimbursement while complying with regulations.
Responsibilities
- Obtain initial and concurrent insurance authorizations for all levels of care
- Review clinical documentation to ensure it supports medical necessity
- Submit clinical information to insurance companies within required timeframes
- Monitor authorization expiration dates and request extensions before expiration
- Communicate authorization decisions and payer requirements to clinical staff
- Track approved days and notify leadership of denials or reductions in care
- Prepare and submit appeals for denied services when appropriate
- Maintain accurate authorization records in the electronic health record (EHR)
- Work collaboratively with Admissions, Clinical, Nursing, and Billing departments
- Verify insurance benefits and coverage when necessary
- Monitor payer portals for authorization updates
- Assist with Medicaid and managed care authorization processes
- Participate in utilization review meetings and case conferences
- Generate reports on authorization status, denials, appeals, and payer trends
- Ensure compliance with Joint Commission, state, federal, and payer regulations
- Maintain confidentiality in accordance with HIPAA regulations
- Perform other duties as assigned
Requirements
- High school diploma required; Associate's or Bachelor's degree preferred
- Minimum of two years of utilization review, case management, medical billing, or behavioral healthcare experience preferred
- Experience in substance use disorder or behavioral health treatment strongly preferred
- Knowledge of ASAM Criteria preferred
- Familiarity with Medicaid, commercial insurance, and managed care plans
- Strong organizational and time management skills
- Excellent verbal and written communication skills
- Ability to prioritize multiple cases in a fast-paced environment
- Proficient in Microsoft Office and electronic health record systems
- Understanding of insurance authorization processes
- Knowledge of medical necessity criteria and documentation standards
- Strong analytical and critical thinking skills
- Excellent customer service and professional communication
- Ability to work independently while collaborating with interdisciplinary teams