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UR / Authorization Specialist

5cdb1896 C39a 4f41 9e9b 869a16e3a666 19000101 000001 · Pembroke, NC, US, Pembroke, NC; Lumberton, NC, US, Lumberton, NC · Remote · Active · ADP Workforce Now Recruiting

Job facts

FieldValue
Company5cdb1896 C39a 4f41 9e9b 869a16e3a666 19000101 000001
TitleUR / Authorization Specialist
Normalized title-
Department / team-
LocationPembroke, NC, United States
Work modelRemote / Remote
Employment typeFull Time
Salary-
Statusactive
ATS providerADP Workforce Now Recruiting
Posted / first seen2026-05-19 / 2026-05-31
Changed / last seen2026-06-06 / 2026-06-06

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Linked records

Company5cdb1896 C39a 4f41 9e9b 869a16e3a666 19000101 000001
Source32164ece-8f26-4358-a838-f054c665c590
ATS providerADP Workforce Now Recruiting

Description

Summary: The UR / Authorization Specialist is responsible for managing all aspects of prior authorizations, concurrent reviews, appeals, and denial management across all service lines. This role serves as the primary point of contact between payers, clinical staff, and organizational leadership to ensure that authorizations are obtained, maintained, and documented in a timely and compliant manner. The UR / Authorization Specialist plays a critical role in protecting organizational revenue and ensuring uninterrupted service delivery for clients receiving SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, Primary Care, and other clinical programs. Essential Duties and Responsibilities: Prior Authorizations Submit prior authorization requests for all service lines including SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, and Primary Care within 24 hours of admission notification. Verify insurance eligibility and payer-specific prior authorization requirements within 2 hours of receiving a referral or admission notification from Clinical/Intake. Compile and submit required clinical documentation to support medical necessity determinations in accordance with payer criteria. Document authorization numbers, approval dates, approved units, and expiration dates in the authorization tracking log and the EHR system upon receipt. Maintain current, payer-specific requirement guides for all managed care organizations (MCOs) including Vaya, Trillium, Cardinal, Eastpointe, Alliance, and Partners. Concurrent Review & Authorization Maintenance Monitor authorization expiration dates and set calendar-based alerts a minimum of 14 days in advance of expiration for all active authorizations. Coordinate with clinical staff to gather clinical updates, treatment summaries, and supporting documentation required for concurrent review submissions. Submit concurrent review requests prior to authorization expiration and document outcomes promptly in the tracking log and EHR. Track active, expiring, and denied authorizations; maintain an accurate, up-to-date authorization inventory at all times. Denial Management & Appeals Identify and document all payer denials upon receipt; escalate to the Director, QM/UR/Compliance within 48 hours of denial receipt. Prepare and submit initial-level appeals within payer-established deadlines, ensuring submission includes all supporting clinical documentation and medical necessity justification. Coordinate peer-to-peer review requests with the Director and clinical leadership when denials are clinically driven. Manage second-level appeals as needed; track outcomes and document all correspondence in the authorization log. Identify patterns in denials and communicate denial trend data to the Director to support systemic corrective action. Authorization Tracking & Reporting Maintain a real-time authorization tracking log reflecting current authorization status, expiration windows, approval units used versus authorized, and denial/appeal status for all active clients. Generate and distribute a weekly authorization dashboard to the Director, QM/UR/Compliance detailing approvals, denials, pending authorizations, and revenue at risk. Ensure all authorization data is accurately entered into the EHR in alignment with billing and clinical records. Support internal audit and billing compliance functions by providing authorization documentation upon request. Payer Communication & Relationship Management Serve as the primary organizational contact for payer utilization management departments across all MCOs and commercial insurers. Maintain current knowledge of payer-specific clinical criteria, portal requirements, submission formats, and appeal procedures. Communicate authorization decisions to clinical staff and the billing department promptly following receipt of payer determinations. Participate in payer-initiated audits or reviews as directed by the Director. Collaboration & Clinical Interface Work directly with clinical staff across all programs to obtain clinical justification documentation needed for authorization submissions and concurrent reviews. Educate clinical staff on documentation standards and requirements that support medical necessity determinations. Partner with the billing department to ensure authorization data aligns with claims submissions and to resolve discrepancies. Participate in team meetings, QI Committee sessions, and department workflow improvement initiatives as directed. Qualifications: Education/Experience Required High school diploma or GED required; associate or bachelor’s degree in healthcare administration, behavioral health, or a related field strongly preferred. Minimum 2 years of experience in utilization review, prior authorization, or managed care in a behavioral health or healthcare setting. Working knowledge of Medicaid and NC Medicaid authorization processes, medical necessity criteria, and payer appeal procedures. Familiarity with North Carolina MCO payer requirements including Vaya Health, Trillium Health Resources, Cardinal Innovations, Eastpointe, Alliance Health, and Partners Health Management. Proficiency with electronic health records (EHR) systems, payer web portals, and standard office software including Microsoft Excel for tracking and reporting. Strong organizational skills with the ability to manage multiple concurrent authorization workflows across multiple service lines. Excellent written and verbal communication skills; ability to interact professionally with payer representatives, clinical staff, and organizational leadership. High attention to detail and ability to meet time-sensitive submission and appeal deadlines consistently. Preferred Experience in behavioral health utilization review specifically, including community-based service lines (ACTT, CST, IIH, MST). Familiarity with residential and higher level of care authorization requirements and concurrent review processes. Experience working in a CCBHC, CARF-accredited, or state-licensed behavioral health organization. Knowledge of NC Tracks and MCO provider portal systems. Key Performance Indicators (KPIs) Performance in this role will be evaluated against the following indicators on a monthly and quarterly basis: Authorization Timeliness 100% of prior authorization requests submitted within 24 hours of admission notification. 100% of concurrent review requests submitted prior to authorization expiration date. Authorization tracking log maintained with zero gaps in active authorization data at any time. Denial & Appeals Management Denial rate tracked monthly; target of less than 10% of submitted authorizations resulting in final denial. 100% of denials escalated to the Director within 48 hours of receipt. 100% of appeal submissions filed within payer-established deadlines. Appeal overturn rate tracked quarterly; target of 50% or greater overturn rate on first-level appeals. Revenue Protection Zero authorization lapses resulting in unbillable services due to missed concurrent review deadlines. Weekly authorization dashboard delivered to the Director by close of business each Friday without exception. Revenue at risk (pending or denied authorizations) reported accurately and communicated proactively. Documentation & Compliance 100% of authorization numbers, approval dates, and unit data entered into the EHR and tracking log within 24 hours of payer determination. Authorization records pass internal audit review with a compliance score of 90% or higher on documentation completeness. Payer-specific requirement guides maintained and reviewed for accuracy on a quarterly basis. Collaboration & Communication Clinical staff receive payer determination communications within 4 business hours of receipt. Billing department receives all authorization data necessary to support claims submission with no delays attributable to UR. Denial trend reports provided to the Director monthly with root cause analysis when denial patterns are identified. Reporting Structure This position reports directly to the Director, QM/UR/Compliance. The UR / Authorization Specialist works in close collaboration with clinical staff across all programs, the billing department, and organizational leadership. Supervisory Responsibilities: None Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This position is primarily remote. The employee is expected to maintain a dedicated, distraction-free home workspace with reliable high-speed internet access sufficient to support EHR use, payer portal access, and video conferencing. Occasional on-site presence at Southeastern Integrated Care locations may be required for onboarding, team meetings, training, or operational needs as determined by the Director. The role requires sustained focus, deadline management, and the ability to handle a high volume of electronic correspondence, portal submissions, and documentation tasks independently. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit for extended periods; use hands to operate computer equipment; talk and hear.

Full job record

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Source ID32164ece-8f26-4358-a838-f054c665c590
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Provideradp_workforcenow
Provider Job Key999077
TitleUR / Authorization Specialist
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CountryUnited States
RegionNC
CityPembroke
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Source URLhttps://workforcenow.adp.com/mascsr/default/mdf/recruitment/recruitment.html?cid=5cdb1896-c39a-4f41-9e9b-869a16e3a666&ccId=19000101_000001&lang=en_US&type=JS&jobId=999077&jwId=9206549432239_1
Apply URLhttps://workforcenow.adp.com/mascsr/default/mdf/recruitment/recruitment.html?cid=5cdb1896-c39a-4f41-9e9b-869a16e3a666&ccId=19000101_000001&lang=en_US&type=JS&jobId=999077&jwId=9206549432239_1
First Seen At2026-05-31 18:27:07Z
Last Seen At2026-06-06 12:46:29Z
Last Checked At2026-06-06 12:46:29Z
Last Changed At2026-06-06 12:46:29Z
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Source Posted At2026-05-19 11:41:00Z
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    "requisitionDescription": "<div><div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-left:157.5pt;text-indent:-157.5pt;' data-pasted=\"true\"><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Summary:&nbsp;</span></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>The UR / Authorization Specialist is responsible for managing all aspects of prior authorizations, concurrent reviews, appeals, and denial management across all service lines. This role serves as the primary point of contact between payers, clinical staff, and organizational leadership to ensure that authorizations are obtained, maintained, and documented in a timely and compliant manner. The UR / Authorization Specialist plays a critical role in protecting organizational revenue and ensuring uninterrupted service delivery for clients receiving SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, Primary Care, and other clinical programs.</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><br></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Essential Duties and Responsibilities:&nbsp;</span></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Prior Authorizations</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Submit prior authorization requests for all service lines including SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, and Primary Care within 24 hours of admission notification.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Verify insurance eligibility and payer-specific prior authorization requirements within 2 hours of receiving a referral or admission notification from Clinical/Intake.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Compile and submit required clinical documentation to support medical necessity determinations in accordance with payer criteria.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Document authorization numbers, approval dates, approved units, and expiration dates in the authorization tracking log and the EHR system upon receipt.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Maintain current, payer-specific requirement guides for all managed care organizations (MCOs) including Vaya, Trillium, Cardinal, Eastpointe, Alliance, and Partners.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Concurrent Review &amp; Authorization Maintenance</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Monitor authorization expiration dates and set calendar-based alerts a minimum of 14 days in advance of expiration for all active authorizations.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Coordinate with clinical staff to gather clinical updates, treatment summaries, and supporting documentation required for concurrent review submissions.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Submit concurrent review requests prior to authorization expiration and document outcomes promptly in the tracking log and EHR.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Track active, expiring, and denied authorizations; maintain an accurate, up-to-date authorization inventory at all times.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Denial Management &amp; Appeals</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Identify and document all payer denials upon receipt; escalate to the Director, QM/UR/Compliance within 48 hours of denial receipt.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Prepare and submit initial-level appeals within payer-established deadlines, ensuring submission includes all supporting clinical documentation and medical necessity justification.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Coordinate peer-to-peer review requests with the Director and clinical leadership when denials are clinically driven.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Manage second-level appeals as needed; track outcomes and document all correspondence in the authorization log.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Identify patterns in denials and communicate denial trend data to the Director to support systemic corrective action.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Authorization Tracking &amp; Reporting</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Maintain a real-time authorization tracking log reflecting current authorization status, expiration windows, approval units used versus authorized, and denial/appeal status for all active clients.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Generate and distribute a weekly authorization dashboard to the Director, QM/UR/Compliance detailing approvals, denials, pending authorizations, and revenue at risk.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Ensure all authorization data is accurately entered into the EHR in alignment with billing and clinical records.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Support internal audit and billing compliance functions by providing authorization documentation upon request.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Payer Communication &amp; Relationship Management</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Serve as the primary organizational contact for payer utilization management departments across all MCOs and commercial insurers.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Maintain current knowledge of payer-specific clinical criteria, portal requirements, submission formats, and appeal procedures.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Communicate authorization decisions to clinical staff and the billing department promptly following receipt of payer determinations.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Participate in payer-initiated audits or reviews as directed by the Director.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Collaboration &amp; Clinical Interface</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Work directly with clinical staff across all programs to obtain clinical justification documentation needed for authorization submissions and concurrent reviews.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Educate clinical staff on documentation standards and requirements that support medical necessity determinations.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Partner with the billing department to ensure authorization data aligns with claims submissions and to resolve discrepancies.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Participate in team meetings, QI Committee sessions, and department workflow improvement initiatives as directed.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><strong>&nbsp;</strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Qualifications:</span></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>&nbsp;</span></u></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Education/Experience</span></u></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Required</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">High school diploma or GED required; associate or bachelor&rsquo;s degree in healthcare administration, behavioral health, or a related field strongly preferred.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Minimum 2 years of experience in utilization review, prior authorization, or managed care in a behavioral health or healthcare setting.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Working knowledge of Medicaid and NC Medicaid authorization processes, medical necessity criteria, and payer appeal procedures.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Familiarity with North Carolina MCO payer requirements including Vaya Health, Trillium Health Resources, Cardinal Innovations, Eastpointe, Alliance Health, and Partners Health Management.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Proficiency with electronic health records (EHR) systems, payer web portals, and standard office software including Microsoft Excel for tracking and reporting.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Strong organizational skills with the ability to manage multiple concurrent authorization workflows across multiple service lines.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Excellent written and verbal communication skills; ability to interact professionally with payer representatives, clinical staff, and organizational leadership.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">High attention to detail and ability to meet time-sensitive submission and appeal deadlines consistently.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Preferred</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Experience in behavioral health utilization review specifically, including community-based service lines (ACTT, CST, IIH, MST).</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Familiarity with residential and higher level of care authorization requirements and concurrent review processes.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Experience working in a CCBHC, CARF-accredited, or state-licensed behavioral health organization.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Knowledge of NC Tracks and MCO provider portal systems.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:8.0pt;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;'><strong><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Key Performance Indicators (KPIs)</span></u></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Performance in this role will be evaluated against the following indicators on a monthly and quarterly basis:</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Authorization Timeliness</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">100% of prior authorization requests submitted within 24 hours of admission notification.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">100% of concurrent review requests submitted prior to authorization expiration date.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Authorization tracking log maintained with zero gaps in active authorization data at any time.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Denial &amp; Appeals Management</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Denial rate tracked monthly; target of less than 10% of submitted authorizations resulting in final denial.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">100% of denials escalated to the Director within 48 hours of receipt.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">100% of appeal submissions filed within payer-established deadlines.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Appeal overturn rate tracked quarterly; target of 50% or greater overturn rate on first-level appeals.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Revenue Protection</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Zero authorization lapses resulting in unbillable services due to missed concurrent review deadlines.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Weekly authorization dashboard delivered to the Director by close of business each Friday without exception.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Revenue at risk (pending or denied authorizations) reported accurately and communicated proactively.</span></li></ul></div><p style='margin-top:0in;margin-right:0in;margin-bottom:4.0pt;margin-left:.5in;font-size:15px;font-family:\"Calibri\",sans-serif;'><br></p><p style='margin-top:0in;margin-right:0in;margin-bottom:4.0pt;margin-left:.5in;font-size:15px;font-family:\"Calibri\",sans-serif;'><br></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Documentation &amp; Compliance</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">100% of authorization numbers, approval dates, and unit data entered into the EHR and tracking log within 24 hours of payer determination.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Authorization records pass internal audit review with a compliance score of 90% or higher on documentation completeness.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Payer-specific requirement guides maintained and reviewed for accuracy on a quarterly basis.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:6.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Collaboration &amp; Communication</span></strong></p><div style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><ul style=\"margin-bottom:0in;\"><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Clinical staff receive payer determination communications within 4 business hours of receipt.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Billing department receives all authorization data necessary to support claims submission with no delays attributable to UR.</span></li><li style=\"margin:0in;font-size:16px;font-family: initial;\"><span style=\"font-family:Calibri;\">Denial trend reports provided to the Director monthly with root cause analysis when denial patterns are identified.</span></li></ul></div><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:8.0pt;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;'><strong><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Reporting Structure</span></u></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>This position reports directly to the Director, QM/UR/Compliance. The UR / Authorization Specialist works in close collaboration with clinical staff across all programs, the billing department, and organizational leadership.&nbsp;</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'><strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Supervisory Responsibilities: </span></strong><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>None</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><br></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:8.0pt;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;'><strong><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Work Environment:</span></u></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>This position is primarily remote. The employee is expected to maintain a dedicated, distraction-free home workspace with reliable high-speed internet access sufficient to support EHR use, payer portal access, and video conferencing. Occasional on-site presence at Southeastern Integrated Care locations may be required for onboarding, team meetings, training, or operational needs as determined by the Director. The role requires sustained focus, deadline management, and the ability to handle a high volume of electronic correspondence, portal submissions, and documentation tasks independently.</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:8.0pt;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;'><strong><u><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>Physical Demands:</span></u></strong></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.</span></p><p style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;margin-bottom:6.0pt;'><span style='font-size:15px;font-family:\"Calibri\",sans-serif;'>While performing the duties of this job, the employee is regularly required to sit for extended periods; use hands to operate computer equipment; talk and hear.&nbsp;</span></p></div></div>\n",
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