Clinical Authorization Specialist (Utilization Review)

Job Description

Job Description

As a leading Residential Treatment Center in the Greater Richmond area, Hallmark Youthcare treats adolescents with emotional and behavioral challenges triggered by trauma. Treatment is provided in a warm and friendly environment by a group of well-trained, highly motivated staff that take pride in delivering quality care in a fast-paced environment.

We are seeking a detail-oriented Clinical Authorization Specialist (Utilization Review) to join our healthcare team. The ideal candidate will have experience in prior authorizations, insurance verification, utilization review, and medical necessity determinations. This role is responsible for ensuring that medical services are appropriately authorized, clinically supported, and compliant with payer guidelines before, during, and after patient care.

The Clinical Authorization Specialist serves as a liaison between healthcare providers, insurance companies, and patients to facilitate timely approvals while minimizing denials and delays in care.

In addition, this role maintains communication with referral sources (CSA/FAPT/IACCT) to coordinate placement and reimbursement standards for transfers from emergency placements and document submission to Magellan for Medicaid consideration.

Key Responsibilities

• Master's degree in health services field.
• Review and process prior authorization requests for medical procedures, diagnostic testing, medications, therapies, and specialty services.
• Evaluate clinical documentation to determine medical necessity using payer guidelines, evidence-based criteria, and insurance policies.
• Perform prospective, concurrent, and retrospective utilization reviews.
• Communicate with physicians, nurses, case managers, and insurance representatives to obtain required clinical documentation.
• Submit authorization requests and monitor status through payer portals and electronic health record (EHR/EMR) systems.
• Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
• Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
• Maintain accurate records of all authorization activities, communications, and determinations.
• Stay current on payer policies, CMS regulations, and utilization management best practices.
• Assist with appeals and peer-to-peer review coordination when necessary.
• Meet productivity, turnaround time, quality, and compliance standards.

Required Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
• Minimum of 2 years of experience in prior authorization, utilization review, medical insurance, case management, including admissions.
• Strong understanding of commercial insurance, Medicare, Medicaid, and managed care plans.
• Experience working with electronic medical records (EMR/EHR) and payer authorization portals.
• Excellent organizational, analytical, and problem-solving skills.
• Strong verbal and written communication abilities.
• Ability to prioritize multiple tasks in a fast-paced healthcare environment.

Benefits:

Set schedule Monday- Friday 9 am- 5pm

Full benefit package available

Matching 401K

Time off accrued each payroll

Free employee meals