Behavioral Health Utilization & Appeals Specialist

Sheppard Pratt Careers; Towson (MD); On-site; USD 68,000 - 109,000; Full time

Benefits offered by this job

Tuition reimbursement

Comprehensive medical, dental and vis​

403b retirement match

Generous paid time off

Employee Assistance Program (EAP)

Job summary

Sheppard Pratt seeks a qualified utilization management professional to provide timely reviews for behavioral health services in Towson, MD. You will coordinate with Medicare, Medicaid, and payer requirements, conduct medical reviews for inpatient and partial hospitalization programs, and document findings across hospital data systems.

You will lead appeals with data-driven analysis to support medical necessity decisions, collaborating with internal stakeholders and external agencies.

Qualifications

• Requires RN license or clinical license (LCPC or LCSW-C).
• Experience in utilization management or behavioral health.
• Knowledge of payer requirements and clinical criteria.

Responsibilities

• Provides timely utilization reviews for behavioral health services.
• Conducts medical reviews for inpatient and partial hospitalization programs and documents in hospital systems.
• Coordinates with Medicare, Medicaid, and commercial payers to ensure CMS and payer requirements.
• Leads appeals process through data-driven analysis to support medical necessity decisions.

Skills

Utilization management

Behavioral health

Payer knowledge

Documentation

Education

RN license

LCPC license

LCSW-C

Job description

Sheppard Pratt seeks a qualified utilization management professional to provide timely reviews for behavioral health services in Towson, MD. You will coordinate with Medicare, Medicaid, and payer requirements, conduct medical reviews for inpatient and partial hospitalization programs, and document findings across hospital data systems.

You will lead appeals with data-driven analysis to support medical necessity decisions, collaborating with internal stakeholders and external agencies.