
Behavioral health and utilization review specialist with 6+ years of experience in mental health, substance abuse treatment, insurance authorizations, case management, and healthcare operations. Skilled in authorization reviews, care coordination, patient advocacy and ability to work collaboratively with clinical teams and insurance providers to secure appropriate levels of care and support successful treatment outcomes.
Conduct authorizations for initial and concurrent reviews to evaluate medical necessity and secure authorization for treatment.
Collaborate with clinicians and providers to collect and submit required clinical documentation.
Track authorization dates, review deadlines, and insurance requirements to prevent gaps in coverage.
Prepare and submit peer to peer review requests and appeal documentation for any denied services.
Communicate with insurance companies to advocate for appropriate levels of care, including MH and SUD DTX, RTC, PHP, IOP and OP.
Monitor insurance guidelines and medical necessity criteria, including ASAM and LOCUS requirements.