Clinical Authorization & Utilization Review Specialist

Ellenco Estágios e Treinamentos; Richmond (VA); On-site; USD 65,000 - 82,000; Full time

Benefits offered by this job

Set schedule Monday–Friday 9 am–5 pm

Full benefit package available

Matching 401K

Time off accrued each payroll

Free employee meals

Job summary

Hallmark Youthcare in the Greater Richmond area seeks a detail-oriented Clinical Authorization Specialist (Utilization Review) to manage prior authorizations, verify insurance, and ensure medical necessity per payer guidelines. You will collaborate with clinicians, insurance reps, and referral sources to minimize denials and delays, while maintaining compliant documentation.

Ideal candidates have 2+ years in authorization/UR, strong knowledge of Medicaid/Medicare, and proficiency with EMR/EHR

Qualifications

• Master’s degree preferred; high school diploma or equivalent required.
• 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 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.

Responsibilities

• 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 and 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 EHR/EMR systems.
• Track approvals, denials, appeals, and expiration dates to ensure continuity of care.
• Identify incomplete documentation and coordinate with providers to obtain necessary information.
• Maintain accurate records of all authorization activities 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.

Skills

Prior authorization

Utilization review

Medical insurance

EMR/EHR systems

Attention to detail

Communication skills

Organization

Problem-solving

Multitasking

Education

Master’s degree in a health services field

High school diploma or equivalent

Associate’s or Bachelor’s degree in healthcare

Tools

EMR/EHR systems

Payer authorization portals

Job description

Hallmark Youthcare in the Greater Richmond area seeks a detail-oriented Clinical Authorization Specialist (Utilization Review) to manage prior authorizations, verify insurance, and ensure medical necessity per payer guidelines. You will collaborate with clinicians, insurance reps, and referral sources to minimize denials and delays, while maintaining compliant documentation.

Ideal candidates have 2+ years in authorization/UR, strong knowledge of Medicaid/Medicare, and proficiency with EMR/EHR