UM SPECIALIST

Qualifications

• Education: High school diploma or GED required. An Associate’s or Bachelor’s is strongly preferred.
• Experience: 1–3 years of experience in prior authorization, medical billing, utilization review (UR), or patient access within a behavioral health or addiction treatment setting.

Specialized SUD & Mental Health Knowledge

Behavioral health payers rely on precise criteria to approve levels of care. Candidates generally must demonstrate

• ASAM Criteria Knowledge: Understanding of the American Society of Addiction Medicine (ASAM) criteria across dimensions (e.g., Level 3.5 Residential vs. Level 2.1 IOP) to support medical necessity for SUD treatment.
• Diagnostic & Clinical Terminology: Familiarity with DSM-5 / ICD-10 coding, medical terminology, and psychiatric terminology (e.g., detox protocols, dual diagnosis, PHP, IOP, outpatient).
• Parity & Regulatory Awareness: Basic understanding of the Mental Health Parity and Addiction Equity Act (MHPAEA), HIPAA compliance, and state-specific behavioral health regulations.
• Payer-Specific Guidelines: Familiarity with commercial insurance (e.g., Optum, Beacon/Carelon, BCBS) and Medicaid/Medicare utilization guidelines for mental health and addiction services.

Technical & Software Skills

• EHR/EMR Systems: Hands-on experience with Carelogic.
• Payer Portals: Proficiency navigating web portals (e.g., Availity, NaviNet, Provider Express) to submit authorizations, check concurrent review statuses, and track approvals.
• Data Management: Proficiency with Microsoft Excel/Google Sheets for tracking authorization lifecycles, expiration dates, and authorized unit counts.

Core Core Competencies

• Clinical Translation: Ability to read therapist notes, biopsychosocial assessments, and nursing documentation, extracting key risk factors (e.g., SI/HI, withdrawal symptoms, relapse risk) to present to insurance medical directors.
• Urgency & Time Management: Ability to manage tight turnaround windows for emergency or acute admissions (e.g., detox or inpatient stabilization requests often require submission within 24 hours of admission).
• Appeal & Peer-to-Peer Coordination: Experience handling initial denial appeals, gathering peer-to-peer review documentation, and coordinating physician-to-doctor discussions.
• Attention to Detail: Precision in matching authorized billing codes (CPT/HCPCS) with authorized dates of service to prevent revenue cycle rejections.