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Position Summary
The Prior Authorization Specialist is responsible for obtaining, tracking, and maintaining insurance and payer authorizations for behavioral health, community-based, and related clinical services provided by Necco Center. This position works closely with therapists, case managers, qualified mental health professionals, nursing staff, program leadership, and external payers to ensure services are authorized, compliant, and reimbursable.
The Prior Authorization Specialist serves as a key liaison between Guardians, clinical teams, billing staff, managed care organizations, Medicaid, and other insurance providers to facilitate timely approval of services and prevent disruptions in care.
Essential Job Functions
- Submit initial and continued service authorization requests to Medicaid managed care organizations, commercial insurance carriers, and other funding sources.
- Monitor authorization status and ensure approvals are obtained before service delivery whenever required.
- Track authorization periods, approved units, and expiration dates.
- Prepare and submit supporting clinical documentation for authorization and reauthorization requests.
- Collaborate with therapists, case managers, nursing staff, residential managers, and behavioral health professionals to obtain necessary documentation.
- Review treatment plans, assessments, and service recommendations to ensure authorization requirements are met.
- Communicate with insurance representatives regarding authorization determinations, denials, and appeals.
- Initiate and coordinate reconsiderations and appeals when services are denied.
- Maintain accurate authorization records within the electronic health record and billing systems.
- Generate reports related to authorization activity, utilization, denials, and approval trends.
- Assist with audits and compliance reviews related to payer requirements and related agencies.
- Monitor changes in Medicaid, managed care, and payer regulations impacting authorization processes.
- Support revenue cycle activities by ensuring authorizations are secured and documented appropriately.
- Maintain confidentiality of all client and organizational information in accordance with HIPAA and agency policies.
- Participate in staff meetings, training, and quality improvement initiatives.
Knowledge, Skills, and Abilities
- Knowledge of healthcare insurance verification and prior authorization processes.
- Understanding of behavioral health, residential treatment, community-based services, and Medicaid reimbursement practices.
- Familiarity with Ohio Department of Behavioral Health, Ohio Medicaid and managed care authorization requirements.
- Strong organizational and time-management skills.
- Ability to manage multiple deadlines and high-volume workloads.
- Excellent verbal and written communication skills.
- Strong attention to detail and accuracy.
- Ability to analyze payer requirements and clinical documentation.
- Proficiency with Microsoft Office applications and electronic health record systems.
- Ability to work independently while collaborating effectively with interdisciplinary teams.
Minimum Qualifications
- High school diploma or GED required.
- Associate degree in healthcare administration, business, behavioral health, medical billing and coding, or related field preferred.
- At least, one (1) year of experience in healthcare administration, insurance verification, medical billing, prior authorization, utilization review, or behavioral health services preferred.
- Experience working with Medicaid, managed care organizations, or behavioral health programs preferred.
- Valid driver's license and insurable driving record may be required.
- Successful completion of all required criminal background checks.
- Background checks including but not limited to FBI, BCI, ARCS, SACWIS/ Alleged Perpetrator Search, & National Sex Offender Registry Search
- An individual is not eligible for employment if either of the following is true:
- The individual’s alleged perpetrator results show a finding of substantiated abuse or neglect within the past ten years.
- The individual is listed on the national sex offender public website.
Preferred Qualifications
- Certified Professional Biller (CPB), Certified Coding Associate (CCA), or similar credentials.
- Experience with behavioral health, residential treatment, or community mental health services.
- Knowledge of Ohio Medicaid regulations and payer authorization requirements.
Physical Requirements
- Ability to sit for extended periods while working at a computer.
- Ability to communicate effectively in person, by telephone, and electronically.
- Ability to occasionally lift up to 15 pounds.
- Ability to perform repetitive hand and keyboard movements.
Working Conditions
- Office-based environment with frequent interaction with clinical and administrative staff.
- May require occasional travel between agency locations.
- Standard business hours with flexibility to meet operational needs.
Performance Expectations
Success in this role is measured by:
- Timely submission of authorization requests.
- Minimal service interruptions due to authorization delays.
- Accurate tracking of approved units and authorization periods.
- Reduction in authorization-related denials.
- Compliance with payer, Medicaid, HIPAA, and organizational requirements.
- Positive collaboration with clinical, billing, and operational teams.
Corporate Citizen
- Practice ruthless pragmatism
- Engage in peer-to-peer feedback
- Know and live the Necco Corporate Culture Principles
- Embody the three essential virtues: humble, hungry, and smart
- Drive your individual performance scorecard results
- Adhere to and contribute to the Necco meeting structure
At Necco, we value diversity and are committed to creating an inclusive and equitable work environment. We embrace individuals of diverse backgrounds, experiences, and perspectives. We believe that a diverse team fosters innovation and creativity, and we actively seek candidates from all races, ethnicities, religions, genders, sexual orientations, abilities, and ages to join our organization. We are dedicated to providing equal opportunities for employment and advancement to all qualified individuals, and we encourage applicants of all backgrounds to apply.
