Clinical Authorization Specialist (Utilization Review)

As a leading Residential Treatment Center in the Greater Richmond area, Hallmark Youthcare treats adolescents with emotional and behavioral challenges triggered by trauma. Treatment is provided in a warm and friendly environment by a group of well-trained, highly motivated staff that take pride in delivering quality care in a fast-paced environment.

The Clinical Authorization Specialist serves as a liaison between healthcare providers, insurance companies, and patients to facilitate timely approvals while minimizing denials and delays in care.

In addition, this role maintains communication with referral sources (CSA/FAPT/IACCT) to coordinate placement and reimbursement standards for transfers from emergency placements and document submission to Magellan for Medicaid consideration.  

• Master's degree in health services field.
• 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, evidence-based criteria, and insurance 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 electronic health record (EHR/EMR) systems.
• Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
• Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
• Maintain accurate records of all authorization activities, communications, 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.

Required Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
• 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 electronic medical records (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.

Benefits:

Set schedule Monday- Friday 9 am- 5pm

Full benefit package available

Matching 401K 

Time off accrued each payroll

Free employee meals