Part-Time Utilization Specialist- OMY

General overview of key roles and responsibilities

The Utilization Reviewer Specialist plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position is part-time, 20-25 hours per week and blends strong relationship-building skills with clinical expertise to navigate complex payer requirements, streamline the authorization process, and support members' and participants' transitions.

This role drives the authorization process by reviewing prospective, retrospective, and concurrent Psychiatric Rehabilitation documents to secure prior authorizations by partnering with the relevant managed care team to complete concurrent review authorizations. Acting as a navigator and liaison between the OMY program and the managed care team, the Specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders.

Essential & CORE Functions

• Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, day authorized, and authorization numbers.

• Coordinates reviews, appeals, and maintains denial logs.

• Consults with appropriate treatment team members for clarification of documentation as needed.                   

• Assist in identifying