Behavioral Health Utilization & Appeals Specialist

Positive Impact Health Centers; Decatur (GA); On-site; USD 52,000 - 76,000; Full time

Job summary

Positive Impact Health Centers seeks an Utilization Review Specialist to coordinate authorization for therapy and IOP services within the Emotional Wellness & Recovery team. The role partners with clinical staff, psychiatry, and payors to gather documentation and assess medical necessity, ensuring timely care.

You will document reviews in the EMR, stay current on payer criteria, assist with PAP enrollment, and support staff training.

Qualifications

• Minimum of 2 years’ experience in behavioral health, substance use treatment, or related clinical setting.
• Experience in utilization review or insurance authorization is preferred.
• Ability to interpret ASAM criteria to clinical documentation.
• Experience with payers and understanding medical necessity requirements.
• Familiarity with ICD-10 codes and behavioral health documentation.
• Proven collaboration within a multidisciplinary team.
• Experience in chart audits or quality management.
• Proficiency with EMR systems and accurate documentation.

Responsibilities

• Serve as liaison between MCOs and clinical staff for timely authorizations.
• Conduct pre-certification, concurrent, discharge, and retrospective reviews.
• Monitor length of stay and communicate updates to care teams.
• Document utilization reviews and communications in the EMR.
• Apply payer requirements and clinical review criteria.
• Collaborate with billing to align documentation and reimbursement.
• Participate in chart audits and quality improvement.
• Assist enrolling clients in PAPs.
• Support staff training on documentation standards.
• Work in a multidisciplinary team for care coordination.
• Report utilization trends and denials to leadership.
• Initiate and manage appeals for denied services.
• Perform other duties as assigned.

Skills

Utilization review

Insurance authorization

Behavioral health

ASAM criteria

EMR documentation

Team collaboration

Education

LSCW/LMHC/LMFT/RN

Job description

Positive Impact Health Centers seeks an Utilization Review Specialist to coordinate authorization for therapy and IOP services within the Emotional Wellness & Recovery team. The role partners with clinical staff, psychiatry, and payors to gather documentation and assess medical necessity, ensuring timely care.

You will document reviews in the EMR, stay current on payer criteria, assist with PAP enrollment, and support staff training.