Utilization Specialist

Preventive Measures• US,

About The Position

The Utilization Specialist supports Preventive Measures’ Georgia behavioral health operations through authorization management and utilization monitoring, and provides quality assurance support for the organization’s Charta AI documentation auditing platform in Washington, DC. The role is intended to improve authorization efficiency, prevent service disruptions, maintain accurate utilization records, and strengthen the accuracy and reliability of AI-driven documentation audits. The contractor collaborates with Operations, Clinical Leadership, Compliance, and Technology teams to identify issues, coordinate resolutions, and support process improvement. For Georgia operations, the specialist monitors and manages authorization requests, prepares submissions through payer portals and systems, checks packets for complete documentation, coordinates with staff to obtain missing materials, tracks decisions and expiration dates, and records approved service details in the EHR and authorization tracker. The specialist monitors units and authorization periods, identifies potential service interruptions and record discrepancies, maintains current tracking information, and escalates concerns to appropriate leadership. For Charta AI, the specialist reviews audit results and selected clinical records to validate findings, identify false positives and false negatives, and assess consistency across service and documentation types. Reviews include documentation completeness, signatures and authentication, service time and unit consistency, treatment-plan discrepancies, billing-code mismatches, duplicate or inconsistent documentation, and Red X flagged notes. The specialist documents recurring inaccuracies and provides examples and recommendations to support system improvements. The position provides administrative authorization and utilization support and reviews Charta AI audit functionality. It does not independently make clinical medical-necessity determinations, approve treatment plans, or make final clinical or compliance determinations. Matters requiring clinical judgment or formal compliance review are escalated to appropriate personnel. All work must comply with organizational confidentiality policies, HIPAA requirements, and applicable data protection standards.

Requirements

Ability to manage authorization requests, payer follow-up, utilization tracking, and related records, as described in the responsibilities.
Ability to review clinical documentation and validate audit findings accurately and consistently.
Ability to identify and communicate documentation, authorization, utilization, and system issues to appropriate teams.
Must comply with confidentiality policies, HIPAA requirements, and applicable data protection standards.

Responsibilities

Monitor and manage initial, continued-service, and modification authorization requests.
Prepare and submit authorization requests through applicable payer portals and systems.
Review authorization packets for completeness before submission and coordinate with clinical and operational staff to obtain outstanding documentation.
Track authorization approvals, denials, pending requests, and expiration dates; follow up with payers on delays, requests for additional information, and administrative issues.
Document approved service types, dates, and units accurately in the EHR and authorization tracker.
Monitor utilization of approved service units and authorization periods; identify approaching limits or expiration dates and flag potential service interruptions.
Identify discrepancies between authorized services, services rendered, and utilization records, and communicate concerns to Georgia Operations leadership.
Maintain an accurate, up-to-date authorization tracking system and provide updates on pending authorizations and outstanding requirements.
Coordinate with clinical leadership on documentation required for continued-service requests and escalate denied authorizations, utilization concerns, and potential service gaps.
Review Charta AI clinical documentation audit results and selected clinical records to validate identified deficiencies.
Identify false-positive and false-negative audit findings and assess consistency and reliability across service categories and documentation types.
Review Charta AI detection of missing or incomplete documentation, missing signatures or authentication, service time and unit inconsistencies, treatment-plan and service documentation discrepancies, billing-code mismatches, duplicate or inconsistent documentation, and Red X flagged notes.
Document recurring audit inaccuracies or gaps in Charta AI’s review capabilities and provide examples and recommendations to support system corrections.
Coordinate with leadership teams to communicate identified system issues and contribute findings to improvements in audit accuracy.
Escalate issues requiring clinical judgment or formal compliance review to appropriate clinical personnel or Compliance leadership.
Comply with organizational confidentiality policies, HIPAA requirements, and applicable data protection standards.