Responsibilities

Prior Authorization and Eligibility

• Initiate, submit, and track prior authorization requests across commercial and managed care payers.
• Verify patient eligibility and benefits prior to authorization submission and confirm coverage, plan requirements, authorization thresholds, deductibles, copays, and other applicable benefit information.
• Ensure authorization requests contain complete and accurate demographic, clinical, and supporting documentation.
• Monitor pending authorization requests through payer portals and direct payer communication and proactively follow up through resolution.
• Document authorization numbers, approved services, CPT codes, effective dates, expiration dates, session or visit limits, and other payer requirements.

Concurrent Reviews and Authorization Management

• Manage concurrent review, continued stay, and authorization renewal requirements for ongoing services.
• Track authorization limits and expiration dates and initiate renewals before existing authorizations are exhausted.
• Maintain accurate authorization records and communicate pending or expiring authorizations to appropriate operational and clinical teams.
• Help prevent gaps in authorization that could result in delayed services or lost reimbursement.

Denials and Appeals

• Review authorization-related denials and determine whether the cause is clinical, administrative, eligibility-related, or procedural.
• Coordinate appropriate corrective action and appeal activity within payer deadlines.
• Prepare clear and accurate appeal documentation and coordinate with clinical and operational teams to obtain supporting information when required.
• Track appeals through resolution and maintain complete documentation of outcomes.
• Identify recurring denial trends and escalate systemic payer or process issues.

Payer and Revenue Cycle Coordination

• Serve as a resource for payer authorization requirements, policies, portals, and workflows.
• Maintain current knowledge of payer requirements and communicate material changes to appropriate teams.
• Coordinate with billing, intake, clinical, credentialing, and contracting teams to resolve authorization-related reimbursement barriers.
• Support single-case agreements, out-of-network authorization requests, and other payer authorization functions as needed.
• Assist with payer audits and utilization management reviews by providing complete authorization records and supporting documentation.

Documentation and Reporting

• Maintain accurate and timely authorization activity within applicable EHR, practice management, and tracking systems.
• Maintain payer authorization matrices and workflow documentation, including submission requirements, turnaround times, authorization limits, and renewal requirements.
• Track authorization performance, including approval rates, denial rates, appeal outcomes, turnaround times, and outstanding requests.
• Identify trends and recommend workflow improvements that strengthen revenue integrity and reduce preventable denials.
• Maintain compliance with HIPAA and all applicable privacy and confidentiality requirements.

Qualifications

• Previous experience in healthcare Revenue Cycle Management, with direct responsibility for prior authorization, eligibility and benefit verification, payer follow-up, or related revenue cycle functions.
• Prior RCM experience supporting behavioral health services is required.
• Strong understanding of prior authorization requirements, payer timelines, submission processes, and authorization tracking.
• Strong understanding of the differences between eligibility, benefits, authorization, and medical necessity requirements.
• Experience working with commercial and managed care payers.
• Experience using payer portals such as Availity, NaviNet, and payer-specific platforms.
• Working knowledge of CPT codes and their relationship to payer authorization requirements.
• Experience managing denials and authorization appeals.
• Experience with EHR, practice management, or other healthcare revenue cycle systems.

Requirements

• Excellent attention to detail and analytical skills.
• Strong organizational skills with the ability to manage multiple authorization queues and deadlines simultaneously.
• Strong written and verbal communication skills and the ability to work effectively with payer representatives and internal operational teams.
• Working knowledge of HIPAA and healthcare privacy requirements.
• US based candidates eligible for employment without sponsorship