UR / Authorization Specialist

UR / Authorization Specialist

The UR / Authorization Specialist is responsible for managing all aspects of prior authorizations, concurrent reviews, appeals, and denial management across all service lines. This role serves as the primary point of contact between payers, clinical staff, and organizational leadership to ensure that authorizations are obtained, maintained, and documented in a timely and compliant manner. The UR / Authorization Specialist plays a critical role in protecting organizational revenue and ensuring uninterrupted service delivery for clients receiving SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, Primary Care, and other clinical programs.

Essential Duties and Responsibilities:

Prior Authorizations

• Submit prior authorization requests for all service lines including SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, and Primary Care within 24 hours of admission notification.
• Verify insurance eligibility and payer-specific prior authorization requirements within 2 hours of receiving a referral or admission notification from Clinical/Intake.
• Compile and submit required clinical documentation to support medical necessity determinations in accordance with payer criteria.
• Document authorization numbers, approval dates, approved units, and expiration dates in the authorization tracking log and the EHR system upon receipt.
• Maintain current, payer-specific requirement guides for all managed care organizations (MCOs) including Vaya, Trillium, Cardinal, Eastpointe, Alliance, and Partners.

Concurrent Review & Authorization Maintenance

• Monitor authorization expiration dates and set calendar-based alerts a minimum of 14 days in advance of expiration for all active authorizations.
• Coordinate with clinical staff to gather clinical updates, treatment summaries, and supporting documentation required for concurrent review submissions.
• Submit concurrent review requests prior to authorization expiration and document outcomes promptly in the tracking log and EHR.
• Track active, expiring, and denied authorizations; maintain an accurate, up-to-date authorization inventory at all times.

Denial Management & Appeals

• Identify and document all payer denials upon receipt; escalate to the Director, QM/UR/Compliance within 48 hours of denial receipt.
• Prepare and submit initial-level appeals within payer-established deadlines, ensuring submission includes all supporting clinical documentation and medical necessity justification.
• Coordinate peer-to-peer review requests with the Director and clinical leadership when denials are clinically driven.
• Manage second-level appeals as needed; track outcomes and document all correspondence in the authorization log.
• Identify patterns in denials and communicate denial trend data to the Director to support systemic corrective action.

Authorization Tracking & Reporting

• Maintain a real-time authorization tracking log reflecting current authorization status, expiration windows, approval units used versus authorized, and denial/appeal status for all active clients.
• Generate and distribute a weekly authorization dashboard to the Director, QM/UR/Compliance detailing approvals, denials, pending authorizations, and revenue at risk.
• Ensure all authorization data is accurately entered into the EHR in alignment with billing and clinical records.
• Support internal audit and billing compliance functions by providing authorization documentation upon request.

Payer Communication & Relationship Management

• Serve as the primary organizational contact for payer utilization management departments across all MCOs and commercial insurers.
• Maintain current knowledge of payer-specific clinical criteria, portal requirements, submission formats, and appeal procedures.
• Communicate authorization decisions to clinical staff and the billing department promptly following receipt of payer determinations.
• Participate in payer-initiated audits or reviews as directed by the Director.

Collaboration & Clinical Interface

• Work directly with clinical staff across all programs to obtain clinical justification documentation needed for authorization submissions and concurrent reviews.
• Educate clinical staff on documentation standards and requirements that support medical necessity determinations.
• Partner with the billing department to ensure authorization data aligns with claims submissions and to resolve discrepancies.
• Participate in team meetings, QI Committee sessions, and department workflow improvement initiatives as directed.

Qualifications:

Education/Experience

Required

• High school diploma or GED required; associate or bachelor's degree in healthcare administration, behavioral health, or a related field strongly preferred.
• Minimum 2 years of experience in utilization review, prior authorization, or managed care in a behavioral health or healthcare setting.
• Working knowledge of Medicaid and NC Medicaid authorization processes, medical necessity criteria, and payer appeal procedures.
• Familiarity with North Carolina MCO payer requirements including Vaya Health, Trillium Health Resources, Cardinal Innovations, Eastpointe, Alliance Health, and Partners Health Management.
• Proficiency with electronic health records (EHR) systems, payer web portals, and standard office software including Microsoft Excel for tracking and reporting.
• Strong organizational skills with the ability to manage multiple concurrent authorization workflows across multiple service lines.
• Excellent written and verbal communication skills; ability to interact professionally with payer representatives, clinical staff, and organizational leadership.
• High attention to detail and ability to meet time-sensitive submission and appeal deadlines consistently.

Preferred

• Experience in behavioral health utilization review specifically, including community-based service lines (ACTT, CST, IIH, MST).
• Familiarity with residential and higher level of care authorization requirements and concurrent review processes.
• Experience working in a CCBHC, CARF-accredited, or state-licensed behavioral health organization.
• Knowledge of NC Tracks and MCO provider portal systems.

Key Performance Indicators (KPIs)

Performance in this role will be evaluated against the following indicators on a monthly and quarterly basis:

Authorization Timeliness

• 100% of prior authorization requests submitted within 24 hours of admission notification.
• 100% of concurrent review requests submitted prior to authorization expiration date.
• Authorization tracking log maintained with zero gaps in active authorization data at any time.

Denial & Appeals Management

• Denial rate tracked monthly; target of less than 10% of submitted authorizations resulting in final denial.
• 100% of denials escalated to the Director within 48 hours of receipt.
• 100% of appeal submissions filed within payer-established deadlines.
• Appeal overturn rate tracked quarterly; target of 50% or greater overturn rate on first-level appeals.

Revenue Protection

• Zero authorization lapses resulting in unbillable services due to missed concurrent review deadlines.
• Weekly authorization dashboard delivered to the Director by close of business each Friday without exception.
• Revenue at risk (pending or denied authorizations) reported accurately and communicated proactively.

Documentation & Compliance

• 100% of authorization numbers, approval dates, and unit data entered into the EHR and tracking log within 24 hours of payer determination.
• Authorization records pass internal audit review with a compliance score of 90% or higher on documentation completeness.
• Payer-specific requirement guides maintained and reviewed for accuracy on a quarterly basis.

Collaboration & Communication

• Clinical staff receive payer determination communications within 4 business hours of receipt.
• Billing department receives all authorization data necessary to support claims submission with no delays attributable to UR.
• Denial trend reports provided to the Director monthly with root cause analysis when denial patterns are identified.

Reporting Structure

This position reports directly to the Director, QM/UR/Compliance. The UR / Authorization Specialist works in close collaboration with clinical staff across all programs, the billing department, and organizational leadership.

Supervisory Responsibilities: None

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This position is primarily remote. The employee is expected to maintain a dedicated, distraction-free home workspace with reliable high-speed internet access sufficient to support EHR use, payer portal access, and video conferencing. Occasional on-site presence at Southeastern Integrated