Prior Authorization/Utilization Specialist

Job Description

Job Description

Anuvia Prevention & Recovery Center | Confidential Job Posting

NOW HIRING Utilization Specialist — MCO Enrollments • Authorizations • Insurance Verification

Department

Administrative

Functional Area

Utilization Management • Payer Operations • Front-End Revenue Cycle

Reports To

Revenue Cycle Manager

FLSA Status

Hourly

Certification

CRCR (Certified Revenue Cycle Representative) preferred

Education

Associate's degree preferred; Bachelor's preferred (or equivalent experience)

License

Valid NC or SC Driver's License required

Work Hours

Monday – Friday, 8:30 AM – 5:00 PM (occasional extended hours as needed)

“Own the authorization workflow that turns clinical care into paid claims — and keeps clients enrolled, verified, and covered from day one.”

Position Summary

The Utilization Specialist is an individual contributor role on Anuvia's Revenue Cycle team, reporting to the Revenue Cycle Manager. The Utilization Specialist owns day-to-day utilization management work — MCO enrollments, insurance verification and lookup, initial authorization submission, authorization tracking, reauthorization workflows, denial support, and basic billing tasks — across Anuvia's programs and locations.

This role is where clinical service delivery meets payer requirements. The accuracy of this work directly protects Anuvia's revenue and every client's access to care.

Because Anuvia's Revenue Cycle team is small and every function has to run every day, the Utilization Specialist is expected to cross-train across the full revenue cycle workflow and be able to step into any UM function on any given day — including intake paperwork review, insurance lookup, MCO enrollment, authorization submission and tracking, denial and appeal support, and basic billing tasks. Coverage, quality, and continuity depend on every team member knowing how to do it all.

To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Duties & Responsibilities

MCO Enrollment & Insurance Verification

• Determines each client's Medicaid MCO and completes MCO enrollment or registration so the client is active in the MCO's system for authorization.
• Verifies insurance eligibility for every assigned client using payer portals, EDI 270/271 transactions, and direct outreach.
• Resolves coordination-of-benefits (COB) exceptions and MCO enrollment gaps (member-not-found, between MCOs, incorrect assignments).
• Documents MCO, plan, member ID, and effective date in the EHR for every client.
• Re-verifies eligibility at the required cadence — monthly for Medicaid / MCO clients; per-payer rule for commercial.

Insurance Lookup, Billing Support & Cross-Training

• Performs insurance lookup on payer portals to confirm coverage, plan details, benefits, copays, and authorization requirements for any client on Anuvia's collective panel — not just the assigned population.
• Supports billing tasks when the team's workload requires — including claim scrubbing, correction of rejections, resubmission of clean claims, and reconciliation of remittance data against authorized services.
• Cross-trains across the full revenue cycle workflow so any team member can absorb another member's work during PTO, illness, or peak volume periods.
• Steps into intake paperwork review when needed, ensuring next-business-day review targets are met every day.
• Participates in team huddles, weekly team meetings, and monthly training refreshers to maintain proficiency across the full workflow.
• Contributes to a small-team culture where every team member is expected to know how to do it all — coverage, quality, and continuity depend on it.

Authorization Submission & Tracking

• Submits initial authorization requests across Medicaid MCO, Medicare, and commercial payers for the assigned client population.
• Maintains the authorization system of record in NetSmart — payer, units, dates, reference numbers, and expiration alerts — for every active authorization.
• Owns end-to-end reauthorization work for assigned programs, adhering to each program's authorization cycle and payer-specific submission requirements.
• Coordinates with Clinical on medical-necessity reauthorizations at least 5 business days before expiration, and submits the reauth once the clinical narrative is complete.
• Runs the daily expiration-alert workflow — any authorization expiring within 5 business days is flagged, worked, and closed the same day.
• Coordinates peer-to-peer review scheduling for denied authorizations.

Intake Paperwork Review & Daily Insurance Review

• Reviews prior-day intake paperwork to ensure insurance and MCO information is complete and accurate.
• Completes the daily insurance review of prior-day intakes — eligibility verified, COB resolved, MCO enrollment confirmed or initiated, initial authorization opened by end of business the next day.
• Participates in the weekly active-client insurance review — coverage, MCO enrollment, active authorization, units remaining, and rate-setup accuracy.
• Flags incomplete packets and returns them to the originating site with a specific correction request.

Payer Communication & Denial Support

• Serves as day-to-day point of contact with MCO and commercial payer representatives for the assigned client population.
• Owns administrative appeal work for assigned denials — timely filing, COB, eligibility, MCO enrollment, missing documentation, rate / setup errors — and packages appeals for submission.
• Routes clinical / medical-necessity denials with a complete appeal packet, tracks response, and confirms outcome.
• Logs every denial in the central denial log with payer, reason, and root cause; contributes to monthly denial-trend review.

Staying Current with Payer Requirements

• Reads MCO and commercial-payer provider bulletins, policy updates, and authorization-rule changes as they are published.
• Contributes to the living payer matrix by flagging changes affecting assigned clients or programs.
• Updates SOPs and NetSmart workflow entries in partnership with the Revenue Cycle Manager as payer requirements change.

Supervisory Responsibilities

This job has no supervisory responsibilities. The Utilization Specialist is an individual contributor reporting directly to the Revenue Cycle Manager.

Competencies

Adaptability

Nurturing

Unity

Vitality

Integrity

Accountability

Adaptability: Innovate and be creative

Nurturing: Demonstrate compassionate care

Unity: Support diversity and motivate one another

Vitality: Challenge the status quo

Integrity: Demand uncompromising ethical standards and inspire trust

Accountability: Take ownership of our decisions and take responsibility for their impact

Communications

• Exhibits good listening and comprehension

• Expresses ideas and thoughts in written form (payer submissions, appeals, denial narratives)

• Expresses ideas and thoughts verbally

• Keeps others adequately informed

• Selects and uses appropriate communication methods (portal, email, phone, fax)

Dependability

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