Utilization Specialist

Job Description

Job Description:\n\n 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 • Commits to doing the best job possible • Follows instructions, responds to management direction • Keeps commitments — deadlines matter in UM work • Meets attendance and punctuality guidelines • Responds to requests for service and assistance • Takes responsibility for own actions and payer outcomes Initiative • Asks for help when needed • Looks for and takes advantage of opportunities to prevent denials • Seeks increased responsibilities • Takes independent actions and calculated risks • Undertakes self-development activities (CRCR, payer bulletins, MCO webinars) • Volunteers readily Problem Solving • Develops alternative solutions for complex payer situations • Gathers and analyzes information skillfully (denial trends, unit reconciliation) • Identifies problems in a timely manner • Resolves problems in early stages before revenue is at risk • Works well in group problem-solving situations Quality • Applies feedback to improve performance • Demonstrates accuracy and thoroughness in every submission • Displays commitment to excellence • Looks for ways to improve and promote quality • Monitors own work to ensure quality — clean submissions the first time Qualifications & Requirements Education & Experience Associate's degree in healthcare administration, business, health information management, or a related field required; Bachelor's preferred (or equivalent combination of education and experience). Two or more years of experience in healthcare revenue cycle, utilization management, insurance verification, or medical billing required — behavioral health preferred. Familiarity with NC Medicaid Tailored Plans, EHR authorization tracking, and payer portals strongly preferred. Language Ability Read, analyze, and interpret payer contracts, regulatory guidance, business, professional, and technical documents. Write clear payer submissions, appeals, and internal communications. Effectively present information and respond to questions from payers, clinical staff, and internal team members. Mathematical Ability Compute basic mathematical skills including units approved, units used, units remaining, and percentages. Fluent with whole numbers, fractions, decimals, and spreadsheet formulas. Reasoning Ability Apply judgment and structured problem-solving to interpret payer policies, resolve authorization exceptions, and complete accurate submissions in situations where limited standardization exists. Interpret a variety of instructions furnished in written, oral, diagram, schedule, or regulatory form. Clerical Ability Knowledge of administrative and clerical procedures — document management, records retention, forms design, correspondence workflows, and healthcare office procedures and terminology. Computer Skills • NetSmart EHR authorization tracking and workflow (strongly preferred) • Payer portals (Availity, NaviNet, UHCprovider, MCO portals) and EDI 270/271 • Microsoft Excel — intermediate proficiency • MS Office applications and other software required of the position • General use of personal computers, printers, and copiers Certificates & Licenses • CRCR (Certified Revenue Cycle Representative) preferred • CPC (Certified Professional Coder) — a plus, not required • Six Sigma Green Belt — a plus, not required • Valid NC or SC Driver's License required Physical Demands In compliance with the Americans with Disabilities Act of 1990 (ADA), the following outlines the physical, mental, and environmental conditions of the essential duties of this position. Physical On the job, the employee must: • Sit for extended periods • Stand and walk within the office • Handle objects (manual dexterity) • Use fine finger movements • Bend, reach, and lift as needed Mental On the job, the employee must be able to: • Communicate orally • Apply general intelligence • Listen • Perform calculations • Read and comprehend • Reason and analyze • Write Environmental On the job, the employee: • Standard office setting • Prolonged computer and telephone work • May work in shared office space • Occasional exposure to distressed clients or families Lift/carry loads: Light (up to 25 lbs.) Why Join Anuvia? — Compensation & Benefits We invest in the people who invest in our clients. Our comprehensive benefits package includes: ❤ Health Benefits: Medical, dental, and vision coverage with low monthly premiums — no waiting period. ⏰ Generous Time Off: Competitive PTO policies to support your work-life balance. ???? Company-Provided Disability Insurance: Short- and long-term coverage included. ???? 401(k) — 7% Employer Contribution: Employer contributes 7% after your first year with immediate vesting. ???? Continuous Learning & Development: Education assistance for CRCR, Six Sigma, and other professional development. ⭐ Career Growth: Grow into UM leadership, provider relations, or revenue-cycle roles as the function matures. The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Ready to Own the Authorization Workflow? Apply Today. Charlotte, NC • Anuvia Prevention & Recovery Center is an Equal Opportunity Employer.