Job Description
Job Description
The Prior Authorization & Billing Specialist plays a critical role in ensuring timely access to mental health services by managing insurance authorizations, billing processes, and reimbursement workflows. This position serves as a key liaison between clinical teams, insurance payers, and patients, ensuring services are authorized, accurately billed, and compliant with regulatory and payer requirements. This role is ideal for a detail-oriented professional passionate about supporting behavioral health access through strong administrative and revenue cycle expertise.
Duties and Responsibilities
Prior Authorization & Utilization Management
- Obtain and manage prior authorizations for outpatient and inpatient mental health services, including therapy, psychiatry, psychological testing, and intensive programs.
- Review clinical documentation to ensure medical necessity and payer compliance.
- Submit authorization requests to insurance companies via portals, phone, or electronic systems.
- Track authorization approvals, denials, expirations, and extensions; proactively follow up to prevent treatment delays.
- Communicate authorization status clearly with clinicians, scheduling staff, and leadership.
- Assist with peer-to-peer reviews and appeals when authorization is denied or partially approved.
Billing & Revenue Cycle Support
- Submit accurate and timely claims for mental health services to commercial, Medicaid, and Medicare payers.
- Verify insurance eligibility, benefits, and coverage limitations prior to services.
- Review Explanation of Benefits (EOBs) and remittance advice for accuracy.
- Identify, research, and resolve claim denials, underpayments, and rejections.
- Post payments and adjustments accurately when applicable.
- Maintain compliance with CPT, ICD-10, and modifier guidelines specific to behavioral health billing.
Administrative & Compliance Responsibilities
- Maintain accurate patient authorization and billing records within electronic health record (EHR) and billing systems.
- Ensure compliance with HIPAA, payer contracts, and internal policies.
- Collaborate with clinical, administrative, and finance teams to optimize workflows and reduce revenue leakage.
- Monitor payer requirements, policy changes, and authorization rules related to mental health services.
- Prepare reports related to authorization turnaround times, denial trends, and billing performance.
- Perform other related duties as assigned.
Required Qualifications
Education and Experience
- High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration or related field preferred.
- Minimum of 2 years of experience in prior authorization, utilization review, medical billing, or revenue cycle operations.
- Experience in mental health or behavioral health services strongly preferred.
Knowledge, Skills, and Abilities
- Strong understanding of prior authorization processes and insurance requirements.
- Knowledge of behavioral health billing practices, CPT and ICD-10 coding, and payer guidelines.
- Excellent attention to detail and organizational skills.
- Ability to manage multiple priorities in a fast-paced environment.
- Strong written and verbal communication skills, including professional interaction with payers and clinical staff.
- Ability to work independently while collaborating effectively with a team.
- Proficiency with EHR systems, billing software, and Microsoft Office applications.
Desired Qualifications
- Experience with Medicaid, Medicare, and commercial behavioral health plans.
- Familiarity with utilization review criteria and medical necessity documentation.
- Prior experience handling insurance appeals and denials.
- Bilingual skills (preferred but not required).