Utilization Specialist

Utilization Specialist

The Utilization Specialist will support Preventive Measures' Georgia behavioral health operations through authorization management and utilization monitoring while providing quality assurance support for the organization's Charta AI documentation auditing platform in Washington, DC. The position is designed to improve authorization efficiency, prevent service disruptions, maintain accurate utilization records, and strengthen the accuracy and reliability of AI-driven documentation audits. The contractor will work collaboratively with Operations, Clinical Leadership, Compliance, and Technology teams to identify issues, coordinate resolutions, and support continuous process improvement.

Role: Lead, Manage, Accountability (LMA)

Primary Job Responsibilities:

A. Authorization & Utilization Management

Authorization Management

• Monitor and manage initial, continued service, and modification authorization requests.

• Prepare and submit authorization requests through applicable payer portals and systems.

• Review authorization packets to ensure all required documentation is complete prior to submission.

• Coordinate with clinical and operational staff to obtain outstanding documentation.

• Track authorization approvals, denials, pending requests, and expiration dates.

• Ensure approved authorization information, including service types, dates, and units, is accurately documented in the EHR and authorization tracker.

• Follow up with payers to resolve authorization delays, requests for additional information, and administrative issues.

Utilization Monitoring

• Monitor utilization of approved service units and authorization periods.

• Identify consumers approaching authorized unit limits or expiration dates.

• Track remaining authorized units and flag potential service interruptions.

• Identify discrepancies between authorized services, services rendered, and utilization records.

• Communicate authorization and utilization concerns to Georgia Operations leadership.

Authorization Tracking & Coordination

• Maintain an accurate and up-to-date authorization tracking system.

• Provide regular updates regarding pending authorizations and outstanding requirements.

• Coordinate with clinical leadership regarding documentation needed to support continued service requests.

• Escalate denied authorizations, utilization concerns, and potential service gaps to appropriate leadership

B. Charta AI Auditing Review AI Audit Validation

• Conduct reviews of Charta AI's clinical documentation audit results.

• Review selected clinical records to validate the accuracy of deficiencies identified by Charta AI.

• Identify false positives where the system incorrectly flags a documentation issue.

• Identify false negatives where the system fails to identify an existing documentation deficiency.

• Evaluate the consistency and reliability of Charta AI's audit findings across service categories and documentation types.

Documentation & Compliance Validation

• Review Charta AI's ability to identify documentation deficiencies, including:

• Missing or incomplete documentation elements.

• Missing signatures and required authentication.

• Service time and unit inconsistencies.

• Treatment plan and service documentation discrepancies.

• Billing code and documentation mismatches.

• Duplicate or inconsistent documentation.

• Red X flagged notes to avoid billing errors.

• Identify recurring audit inaccuracies or potential gaps in Charta AI's review capabilities.

System Improvement & Issue Resolution

• Provide examples and recommendations to support corrections to Charta AI's auditing functionality.

• Coordinate with the leadership teams to communicate identified system issues.

4. Performance Expectations

Georgia Authorization Management

• Authorization requests are submitted accurately and within applicable payer deadlines.

• Authorization expiration dates and utilization limits are monitored proactively.

• Pending authorizations receive consistent follow-up.

• Authorization records remain complete, accurate, and current.

• Potential service interruptions are identified and escalated promptly.

Charta AI Review

• Documentation samples are reviewed accurately and consistently.

• False positives, false negatives, and recurring audit errors are documented.

• Identified issues are communicated to the appropriate teams.

• Findings contribute to measurable improvements in Charta AI audit accuracy.

5. Reporting & Communication

The Utilization Specialist will coordinate with Georgia Operations leadership for authorization-related responsibilities and designated Preventive Measures Inc leadership for Charta AI review activities.

6. Scope Limitations

• The Utilization Specialist will provide administrative authorization and utilization management support and review Charta AI audit functionality.

• The contractor will not independently make clinical medical necessity determinations, approve treatment plans, or make final clinical or compliance determinations.

• Issues requiring clinical judgment or formal compliance review will be escalated to the appropriate clinical personnel or Compliance leadership.

• All activities must comply with organizational confidentiality policies, HIPAA requirements, and applicable data protection standards.

Core Values:

• Do the Right Thing - We approach decisions with integrity, honesty, and transparency.
• Own It - We take full responsibility for our role, commitments, and performance.
• Serve First - We show up with a mindset of service to colleagues, clients, and the mission.
• Choose Solutions - We display a solution-oriented mindset and bring constructive energy to challenges.
• Lead with Respect - We treat everyone with respect, communicate professionally, and handle conflict maturely.
• Commit to the Goal - We demonstrate focus, follow-through, and accountability to team objectives.