Job Description

The Prior Authorization & Billing Specialist plays a critical role in ensuring timely access to mental health services by managing insurance authorizations, billing processes, and reimbursement workflows. This position serves as a key liaison between clinical teams, insurance payers, and patients, ensuring services are authorized, accurately billed, and compliant with regulatory and payer requirements. This role is ideal for a detail-oriented professional passionate about supporting behavioral health access through strong administrative and revenue cycle expertise.

Duties and Responsibilities

Prior Authorization & Utilization Management

Obtain and manage prior authorizations for outpatient and inpatient mental health services, including therapy, psychiatry, psychological testing, and intensive programs. Review clinical documentation to ensure medical necessity and payer compliance. Submit authorization requests to insurance companies via portals, phone, or electronic systems. Track authorization approvals, denials, expirations, and extensions; proactively follow up to prevent treatment delays. Communicate authorization status clearly with clinicians, scheduling staff, and leadership. Assist with peer-to-peer reviews and appeals when authorization is denied or partially approved.

Billing & Revenue Cycle Support

Submit accurate and timely claims for mental health services to commercial, Medicaid, and Medicare payers. Verify insurance eligibility, benefits, and coverage limitations prior to services. Review Explanation of Benefits (EOBs) and remittance advice for accuracy. Identify, research, and resolve claim denials, underpayments, and rejections. Post payments and adjustments accurately when applicable. Maintain compliance with CPT, ICD-10, and modifier guidelines specific to behavioral health billing.

Administrative & Compliance Responsibilities

Maintain accurate patient authorization and billing records within electronic health record (EHR) and billing systems. Ensure compliance with HIPAA, payer contracts, and internal policies. Collaborate with clinical, administrative, and finance teams to optimize workflows and reduce revenue leakage. Monitor payer requirements, policy changes, and authorization rules related to mental health services. Prepare reports related to authorization turnaround times, denial trends, and billing performance. Perform other related duties as assigned.

Required Qualifications

Education and Experience

High school diploma or equivalent required; associate or bachelor's degree in healthcare administration or related field preferred. Minimum of 2 years of experience in prior authorization, utilization review, medical billing, or revenue cycle operations. Experience in mental health or behavioral health services strongly preferred.

Knowledge, Skills, and Abilities

Strong understanding of prior authorization processes and insurance requirements. Knowledge of behavioral health billing practices, CPT and ICD-10 coding, and payer guidelines. Excellent attention to detail and organizational skills. Ability to manage multiple priorities in a fast-paced environment. Strong written and verbal communication skills, including professional interaction with payers and clinical staff. Ability to work independently while collaborating effectively with a team. Proficiency with EHR systems, billing software, and Microsoft Office applications.

Desired Qualifications

Experience with Medicaid, Medicare, and commercial behavioral health plans. Familiarity with utilization review criteria and medical necessity documentation. Prior experience handling insurance appeals and denials. Bilingual skills (preferred but not required).

Location and Work Type

Work Type:

On-site

Schedule:

Full-time Monday - Friday 9:00 AM - 5:00 PM

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