Medical Billing/Utilization Review Specialist

Turning Point Behavioral Health•Madison, SD

About The Position

Turning Point Behavioral Health is committed to providing exceptional care and service with compassion. We strive to provide a family of employees who feel valued and supported in an environment that inspires excellence and fulfilment. Our services support individuals seeking behavioral health and substance use disorder treatment, with South Dakota serving as the primary location of responsibility for this role. The Medical Billing / Utilization Review Specialist will be responsible for supporting the financial and clinical authorization processes for residential behavioral health and substance use disorder services. This position ensures accurate billing, timely claims submission, insurance verification, authorization management, and continued stay review coordination. The Medical Billing / Utilization Review Specialist works closely with admissions, clinical, and leadership teams to ensure that services are appropriately authorized, documented, billed, and reimbursed in accordance with payer expectations and state and federal requirements. This role requires a highly organized and detail-oriented professional who is committed to helping maintain continuity of care and uninterrupted operations through strong revenue cycle and utilization review practices.

Requirements

High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration, business, billing, coding, or related field preferred.
Experience in behavioral health billing, substance use disorder treatment billing, medical billing, utilization review, insurance verification, or revenue cycle management strongly preferred.
Knowledge of Medicaid, Medicare, commercial insurance, prior authorization processes, and payer requirements for residential treatment preferred.
Experience with CPT, HCPCS, ICD-10 coding, UB-04 and/or CMS-1500 claim forms, and electronic billing systems preferred.
Minimum of 5 years of experience in a residential treatment setting preferred.
Familiarity with South Dakota payer systems, behavioral health reimbursement, and regional insurance processes strongly preferred.
Strong knowledge of behavioral health billing processes, payer requirements, and utilization review practices.
Understanding of medical necessity criteria, continued stay review processes, and insurance authorization requirements for residential treatment.
Strong attention to detail and ability to maintain accurate and timely documentation and billing records.
Ability to work collaboratively with clinical, admissions, and administrative staff in a fast-paced treatment environment.
Effective organizational, communication, and problem-solving skills.
Ability to identify reimbursement issues, resolve claim concerns, and support appeal processes when needed.
Commitment to confidentiality, professionalism, and compliance with all applicable standards and regulations.
Strong working knowledge of revenue cycle management and payer communication processes.

Responsibilities

Review and process billing for residential behavioral health and substance use disorder treatment services.
Verify insurance eligibility, benefits, authorizations, and payer requirements prior to and throughout treatment episodes.
Submit clean claims and monitor claims through the full revenue cycle process to support timely reimbursement.
Manage utilization review functions, including initial authorizations, concurrent reviews, continued stay requests, peer review coordination, and payer communication.
Collaborate with clinical staff to ensure documentation supports medical necessity, level of care, and continued stay criteria.
Track authorization periods, payer deadlines, denials, underpayments, and appeal opportunities.
Maintain accurate client account records, billing data, and insurance information in organizational systems.
Assist with reimbursement follow-up and collections involving Medicaid, Medicare, and commercial insurance payers.
Identify trends related to denied, delayed, or underpaid claims and communicate areas needing corrective action.
Ensure compliance with payer guidelines, organizational standards, and all applicable state and federal regulations.
Support operational improvement in billing, utilization review, and reimbursement workflows, particularly for South Dakota-based services.
Communicate effectively with insurance representatives, internal staff, and leadership regarding authorization and billing issues.
Help ensure continuity of operations by reducing avoidable disruptions in reimbursement and authorization processes.