Clinical Utilization Specialist

The Clinical Utilization (CU) Specialist assists with the coordination and administration of the organization’s prior authorization process. This role is responsible for coordinating with clinical staff and preparing comprehensive clinical summaries to support initial and ongoing prior authorization requests. The role also entails tracking open prior authorization requests, outcomes, and trends related to prior authorizations. The CU specialist supports the Quality Improvement department by assisting with monitoring service delivery trends, identifying patterns and gaps in care or documentation, and supporting ongoing quality improvement efforts. Additionally, this position provides education, guidance, and consultation to clinical staff regarding best documentation practices, regulatory compliance, and quality standards to promote consistent, high-quality client care.

Key Responsibilities & Role Highlights:  

• Review clinical documentation and prepare comprehensive clinical summaries to support initial and
  ongoing prior authorization requests.
• Collaborate closely with Billing to ensure authorization requests are complete, submitted within
  required timeframes and followed through to final determination.
• Monitor and track authorizations, including approvals, denials, expiration dates, requested units,
  approved units and required follow-up.
• Track authorization denials and appeals, including outcomes and trends, and assist in gathering the
  clinical documentation and supporting information needed for appeals.
• Maintain a strong working knowledge of authorization requirements, processes, timelines, and
  documentation standards across Medicaid managed care plans and other payers.
• Maintain and analyze data related to authorizations, denials, appeals, turnaround times, and payer
  trends to identify challenges, monitor performance, and support process improvement.
• Develop and maintain strong working relationships with clinical leaders and staff to efficiently
  obtain information needed for authorization requests, clarify clinical information, and ensure
  documentation supports the services being requested.
• As capacity allows, assist with chart reviews and other utilization review activities related to
  documentation, medical necessity, service utilization, and payer requirements.
• Identify recurring documentation gaps, payer concerns, and process barriers and collaborate with
  Shelby, clinical leadership, Billing, and Quality Improvement to develop and implement solutions.

Education & Experience Requirements:  

• Bachelor’s degree in a mental health-related field, business management, or health care administration preferred. An associate’s degree with relevant experience may be considered.
• Minimum of 3 years of clinical experience in the mental health field; experience in Quality Improvement or process improvement is preferred.
• Licensed LSW, LPC, LISW, LPCC, RN preferred.
• Proficiency in Microsoft Word, PowerPoint, Excel (including data entry, formulas, and pivot tables).
• Ability to handle confidential information with discretion.
• Strong knowledge of behavioral health practices, quality improvement standards, regulatory
  requirements, compliance, and Health Information Management processes.
• Strong analytical and problem-solving skills, including the ability to review and interpret data,
  identify trends, define problems, establish facts, and develop effective recommendations.
• Ability to develop, implement, monitor, and evaluate quality and performance improvement
  initiatives.
• Demonstrates strong attention to detail, sound judgment, confidentiality, and personal integrity.
• Demonstrates a positive attitude, commitment to providing superior service, and enthusiastic
  support of the agency’s mission.
• Ability to collaborate effectively with staff, leadership, and various departments across the
  organization.
• Must possess a valid driver’s license, reliable transportation, and meet agency driving
  requirements.
• Required CPI certification within 90 days of hire.
• Must be at least 21 years of age.
• Bachelor’s degree in a mental health-related field, business management, or health care administration preferred. An associate’s degree with relevant experience may be considered.
• Minimum of 3 years of clinical experience in the mental health field; experience in Quality Improvement or process improvement is preferred.
• Licensed LSW, LPC, LISW, LPCC, RN preferred.
• Proficiency in Microsoft Word, PowerPoint, Excel (including data entry, formulas, and pivot tables).
• Ability to handle confidential information with discretion.