Clinical Utilization Specialist

Unison Health•Toledo, OH

About The Position

The Clinical Utilization Specialist assists with coordinating and administering the organization’s prior authorization process. The role coordinates with clinical staff and prepares clinical summaries to support initial and ongoing authorization requests, tracks requests and outcomes, and monitors authorization trends. The specialist also supports the Quality Improvement department by monitoring service delivery trends, identifying gaps in care or documentation, and contributing to quality improvement efforts. The position provides clinical staff with education, guidance, and consultation on documentation practices, regulatory compliance, and quality standards to promote consistent, high-quality client care.

Requirements

At least 3 years of clinical experience in the mental health field.
Proficiency in Microsoft Word, PowerPoint, and Excel, including data entry, formulas, and pivot tables.
Ability to handle confidential information with discretion.
Strong knowledge of behavioral health practices, quality improvement standards, regulatory requirements, compliance, and Health Information Management processes.
Strong analytical and problem-solving skills, including the ability to interpret data, identify trends, define problems, establish facts, and develop recommendations.
Ability to develop, implement, monitor, and evaluate quality and performance improvement initiatives.
Strong attention to detail, sound judgment, confidentiality, and personal integrity.
Positive attitude, commitment to superior service, and enthusiastic support of the agency’s mission.
Ability to collaborate effectively with staff, leadership, and departments across the organization.
Valid driver’s license, reliable transportation, and ability to meet agency driving requirements.
Must obtain CPI certification within 90 days of hire.
Must be at least 21 years of age.

Nice To Haves

Bachelor’s degree in a mental health-related field, business management, or health care administration.
Associate’s degree with relevant experience may be considered.
Experience in Quality Improvement or process improvement.
Licensure as an LSW, LPC, LISW, or LPCC, or RN qualification.

Responsibilities

Review clinical documentation and prepare comprehensive summaries for initial and ongoing prior authorization requests.
Collaborate with Billing to ensure authorization requests are complete, submitted on time, and followed through to a final determination.
Track authorization approvals, denials, expiration dates, requested and approved units, and required follow-up.
Track authorization denials and appeals, including outcomes and trends, and help gather clinical documentation and supporting information for appeals.
Maintain knowledge of authorization requirements, processes, timelines, and documentation standards across Medicaid managed care plans and other payers.
Maintain and analyze authorization, denial, appeal, turnaround-time, and payer-trend data to identify challenges, monitor performance, and support process improvement.
Build working relationships with clinical leaders and staff to obtain information for authorization requests, clarify clinical information, and ensure documentation supports requested services.
As capacity allows, assist with chart reviews and other utilization review activities related to documentation, medical necessity, service utilization, and payer requirements.
Identify recurring documentation gaps, payer concerns, and process barriers, and collaborate with Shelby, clinical leadership, Billing, and Quality Improvement on solutions.
Support quality improvement efforts, including monitoring service delivery trends and identifying patterns and gaps in care or documentation.
Educate, guide, and consult with clinical staff regarding documentation practices, regulatory compliance, and quality standards.