Behavioral Health Authorizations Specialist

Job Description

Job Description

Description:

POSITION SUMMARY:

The Behavioral Health Authorizations Specialist manages the full prior authorization lifecycle for SCCS across all commercial, managed care, and applicable Medi-Cal payers. As SCCS grows its referral volume and expands its payer base, this role is central to ensuring that services are authorized accurately and on time, that denials are challenged without delay, and that no appointment is lost to an avoidable authorization gap. This position sits at the intersection of payer relations, clinical documentation, and revenue integrity. It requires deep fluency in behavioral health payer requirements, a proactive approach to tracking and follow-up, and the organizational precision to manage a high volume of authorization requests across multiple payers and programs simultaneously. The role reports directly to the Chief Marketing and Development Officer and works in close coordination with the intake, clinical, credentialing, and billing teams.

JOB DUTIES & RESPONSIBILITIES:

Prior Authorization

• Initiate, submit, and track prior authorization requests for all outpatient behavioral health services requiring payer approval across SCCS’s full payer mix, including Cigna/Evernorth, Aetna, Blue Shield of California, Kaiser, Magellan EAP, Carelon/Anthem, IEHP, CalOptima, and any additional contracted payers. Submission must be completed before the client’s first authorized appointment.
• Verify that each PA request includes accurate and complete clinical and demographic information. Identify when supporting documentation (treatment plans, assessment summaries, DSM-5 diagnoses) is required and coordinate with clinical staff to obtain it within payer-required timeframes.
• Monitor all open authorization requests through payer portals and direct payer contact. Proactively follow up on pending requests before approval windows expire. No PA request is considered complete until an authorization number is received and documented.

Concurrent and Continued Stay Reviews

• Manage concurrent review and continued stay authorization requests for ongoing outpatient services. Track authorization session limits by payer and client, and initiate continued stay reviews before authorized sessions are exhausted to prevent gaps in care.
• Maintain a real-time tracking log of all active authorizations, including authorization numbers, session limits, expiration dates, and renewal status. Alert clinical and scheduling teams when sessions are running low or renewals are pending.

Denials and Appeals

• Review all authorization denials promptly. Identify the denial reason, determine whether the denial is clinical, administrative, or procedural, and initiate the appropriate appeal pathway without delay. Every denial receives a response; no denial is written off without review.
• Draft appeal letters that are precise, clinically grounded, and submitted within payer-required deadlines. Coordinate with clinicians to obtain supporting documentation. Track all appeals through resolution and document outcomes in the EHR and authorization log.
• Track denial patterns by payer, CPT code, and denial reason. Report recurring denial trends to the CMDO and flag systemic issues for escalation to the contracting or credentialing teams as appropriate.

Payer Coordination and Benefit Verification

• Verify insurance eligibility and benefits in real time for all clients requiring authorization before scheduling, using payer portals (Availity, Navinet, and payer-specific platforms) or direct payer contact. Confirm active coverage, plan type, deductible status, co-pay, out-of-pocket maximum, behavioral health carve-out provisions, and PA trigger thresholds. Eligibility verification is a foundational step and must be completed before any authorization request is submitted.
• Maintain current working knowledge of each contracted payer’s authorization policies, behavioral health benefit structures, and any plan updates that affect SCCS’s ability to bill for services. Proactively communicate payer changes to the intake and clinical teams.
• Serve as the primary point of contact for payer representatives on authorization-related inquiries. Communicate authorization status, session limits, and any payer-related barriers directly to intake staff and clinical supervisors.

Documentation and Reporting

• Document all authorization activity in MyEvolve/EHR at the time of each action, including submission date, payer, authorization number, approved CPT codes, session limits, expiration dates, denial reasons, and appeal outcomes.
• Produce regular authorization performance reports for the CMDO covering approval rates, denial rates, appeal win rates, average turnaround times, and outstanding requests by payer. Flag barriers and recommend process improvements based on data trends.
• Maintain compliance with HIPAA and 42 CFR Part 2 across all payer communications, documentation, and PHI handling. Support payer audit readiness by ensuring authorization records are complete, current, and accessible.

Payer Matrix, Process Documentation, and Training

• Own and maintain a current payer authorization matrix documenting PA requirements, submission workflows, portal access, turnaround standards, and session limits by payer and service type. This document is a living reference; it must be updated whenever a payer changes its requirements or SCCS adds a new contracted payer.
• Develop and maintain authorization process documentation and training materials for use by intake, scheduling, and clinical staff. As SCCS grows its payer mix, this role is responsible for keeping internal teams current on what each payer requires and when.

Expanded Payer Functions

• Manage commercial benefit verification for clients requiring authorization, coordinating with the Intake Specialist team to ensure eligibility and benefit information is complete before PA submission. As this role matures, it is expected to take on single-case agreement (SCA) coordination, out-of-network authorization requests, and proactive tracking of authorization requirements for new payer contracts as SCCS’s payer mix expands.

Cross-Team Support and Payer Audits

• Support the credentialing and contracting teams by identifying and escalating payer barriers, authorization delays, and denial trends that may indicate a broader contracting or network status issue. Participate in payer audits and utilization management reviews as requested, providing authorization records, data summaries, and supporting documentation.

QUALIFICATIONS

Required

• In-depth knowledge of prior authorization (PA) requirements, timelines, and submission processes for behavioral health outpatient services across SCCS’s active payer mix, including Cigna/Evernorth, Aetna, Blue Shield of California, Kaiser, Magellan EAP, Carelon/Anthem, and Medi-Cal managed care plans (including CalOptima and IEHP).
• Strong working knowledge of the distinction between eligibility (active coverage), authorization (payer approval for a specific service), and medical necessity criteria as applied to behavioral health. Candidates must be able to articulate this distinction and demonstrate it in practice.
• Proficiency with payer portals including Availity, Navinet, and payer-specific platforms; experience navigating portal-based PA submission, status tracking, and documentation upload.
• Working knowledge of CPT codes relevant to behavioral health outpatient services and how payer authorization requirements vary by code across SCCS’s active and growing payer mix. As SCCS contracts with new payers, this role is expected to learn and apply new payer-specific authorization requirements quickly.
• Proficiency in EHR systems (MyEvolve preferred) and Microsoft Office; ability to manage multiple concurrent authorization queues across payers and programs without lapses in tracking or follow-up.
• Exceptional verbal and written communication skills; ability to interact professionally and persuasively with payer representatives, communicate authorization status clearly to clinical and intake staff, and draft appeal letters that are precise, evidence-based, and deadline-compliant.
• Working knowledge of HIPAA Privacy and Security Rules and 42 CFR Part 2 confidentiality requirements. HIPAA certification required within 30 days of hire if not already held.

Preferred

• Prior experience in a behavioral health outpatient, mental health, or community-based services environment, with familiarity across both county Medi-Cal and commercial insurance authorization requirements.
• Experience with utilization review processes, concurrent authorization requests, and continued stay reviews for outpatient behavioral health services.
• Familiarity with California-specific payer requirements, CalAIM’s impact on Medi-Cal managed care authorization rules, and IEHP and CalOptima plan structures.
• English and Spanish bilingual fluency strongly preferred given SCCS’s service population across San Bernardino and Orange Counties and beyond.
• Valid California driver’s license, proof of automobile insurance, and CPR/First Aid certification within 30 days of hire.

KNOWLEDGE, SKILLS & ABILITIES:

• Mastery of payer-specific authorization workflows, portal navigation, and behavioral health benefit structures across commercial, managed care, EAP, and Medi-Cal plans.
• Meticulous attention to detail and strong organizational skills; ability to manage a high-volume authorization queue with zero tolerance for expired authorizations or missed follow-up deadlines.
• Analytical problem-solving ability; skilled at identifying the root cause of a denial and selecting the right remediation strategy, whether administrative correction, clinical addendum, or formal appeal.
• Exceptional verbal and written communication skills; able to interact confidently with payer representatives, write clear and persuasive appeal letters, and translate complex authorization requirements into plain language for clinical and intake staff.
• Strong sense of urgency combined with precision; this role directly affects whether clients receive services and whether SCCS receives reimbursement. Speed and accuracy are equally required.
• Culturally responsive communication style suited to SCCS’s diverse service population across San Bernardino and Orange Counties and beyond.

WORK ENVIRONMENT

Role operates in an office environment

• Required to occasionally lift and carry 10 to 20 pounds.
• Valid California driver’s license, insurance and reliable transportation
• Regularly required to sit and use a computer and telephone for extended periods. Regularly required to stand, walk, and climb stairs. May be required to travel between SCCS sites and attend external meetings across San Bernardino and Orange Counties and beyond.

EOE, INCLUDING DISABILITY/VETS

We are an equal opportunity employer and consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, medical condition, genetic information, marital status, veteran status, or any other protected characteristic under California law.