UM SPECIALIST

UM SPECIALIST# UM SPECIALISTWaverly , OH 45690## 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 KnowledgeBehavioral 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.
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