Utilization Specialist

Anuvia Prevention and Recovery Center, Inc. • Charlotte, NC

1d • Onsite

About The Position

The Utilization Specialist is an individual contributor role on Anuvia's Revenue Cycle team, reporting to the Revenue Cycle Manager. The Utilization Specialist owns day-to-day utilization management work — MCO enrollments, insurance verification and lookup, initial authorization submission, authorization tracking, reauthorization workflows, denial support, and basic billing tasks — across Anuvia's programs and locations. This role is where clinical service delivery meets payer requirements. The accuracy of this work directly protects Anuvia's revenue and every client's access to care. Because Anuvia's Revenue Cycle team is small and every function has to run every day, the Utilization Specialist is expected to cross-train across the full revenue cycle workflow and be able to step into any UM function on any given day — including intake paperwork review, insurance lookup, MCO enrollment, authorization submission and tracking, denial and appeal support, and basic billing tasks. Coverage, quality, and continuity depend on every team member knowing how to do it all. To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Requirements

• Associate's degree in healthcare administration, business, health information management, or a related field required; Bachelor's preferred (or equivalent combination of education and experience).
• Two or more years of experience in healthcare revenue cycle, utilization management, insurance verification, or medical billing required — behavioral health preferred.
• Familiarity with NC Medicaid Tailored Plans, EHR authorization tracking, and payer portals strongly preferred.
• Read, analyze, and interpret payer contracts, regulatory guidance, business, professional, and technical documents.
• Write clear payer submissions, appeals, and internal communications.
• Effectively present information and respond to questions from payers, clinical staff, and internal team members.
• Compute basic mathematical skills including units approved, units used, units remaining, and percentages.
• Fluent with whole numbers, fractions, decimals, and spreadsheet formulas.
• Apply judgment and structured problem-solving to interpret payer policies, resolve authorization exceptions, and complete accurate submissions in situations where limited standardization exists.
• Interpret a variety of instructions furnished in written, oral, diagram, schedule, or regulatory form.
• Knowledge of administrative and clerical procedures — document management, records retention, forms design, correspondence workflows, and healthcare office procedures and terminology.
• NetSmart EHR authorization tracking and workflow (strongly preferred)
• Payer portals (Availity, NaviNet, UHCprovider, MCO portals) and EDI 270/271
• Microsoft Excel — intermediate proficiency
• MS Office applications and other software required of the position
• General use of personal computers, printers, and copiers
• Sit for extended periods
• Stand and walk within the office
• Handle objects (manual dexterity)
• Use fine finger movements
• Bend, reach, and lift as needed
• Communicate orally
• Apply general intelligence
• Listen
• Perform calculations
• Read and comprehend
• Reason and analyze
• Write
• Lift/carry loads: Light (up to 25 lbs.)

Nice To Haves

• CRCR (Certified Revenue Cycle Representative) preferred
• CPC (Certified Professional Coder) — a plus, not required
• Six Sigma Green Belt — a plus, not required

Responsibilities

• Determines each client's Medicaid MCO and completes MCO enrollment or registration so the client is active in the MCO's system for authorization.
• Verifies insurance eligibility for every assigned client using payer portals, EDI 270/271 transactions, and direct outreach.
• Resolves coordination-of-benefits (COB) exceptions and MCO enrollment gaps (member-not-found, between MCOs, incorrect assignments).
• Documents MCO, plan, member ID, and effective date in the EHR for every client.
• Re-verifies eligibility at the required cadence — monthly for Medicaid / MCO clients; per-payer rule for commercial.
• Performs insurance lookup on payer portals to confirm coverage, plan details, benefits, copays, and authorization requirements for any client on Anuvia's collective panel — not just the assigned population.
• Supports billing tasks when the team's workload requires — including claim scrubbing, correction of rejections, resubmission of clean claims, and reconciliation of remittance data against authorized services.
• Cross-trains across the full revenue cycle workflow so any team member can absorb another member's work during PTO, illness, or peak volume periods.
• Steps into intake paperwork review when needed, ensuring next-business-day review targets are met every day.
• Participates in team huddles, weekly team meetings, and monthly training refreshers to maintain proficiency across the full workflow.
• Contributes to a small-team culture where every team member is expected to know how to do it all — coverage, quality, and continuity depend on it.
• Submits initial authorization requests across Medicaid MCO, Medicare, and commercial payers for the assigned client population.
• Maintains the authorization system of record in NetSmart — payer, units, dates, reference numbers, and expiration alerts — for every active authorization.
• Owns end-to-end reauthorization work for assigned programs, adhering to each program's authorization cycle and payer-specific submission requirements.
• Coordinates with Clinical on medical-necessity reauthorizations at least 5 business days before expiration, and submits the reauth once the clinical narrative is complete.
• Runs the daily expiration-alert workflow — any authorization expiring within 5 business days is flagged, worked, and closed the same day.
• Coordinates peer-to-peer review scheduling for denied authorizations.
• Reviews prior-day intake paperwork to ensure insurance and MCO information is complete and accurate.
• Completes the daily insurance review of prior-day intakes — eligibility verified, COB resolved, MCO enrollment confirmed or initiated, initial authorization opened by end of business the next day.
• Participates in the weekly active-client insurance review — coverage, MCO enrollment, active authorization, units remaining, and rate-setup accuracy.
• Flags incomplete packets and returns them to the originating site with a specific correction request.
• Serves as day-to-day point of contact with MCO and commercial payer representatives for the assigned client population.
• Owns administrative appeal work for assigned denials — timely filing, COB, eligibility, MCO enrollment, missing documentation, rate / setup errors — and packages appeals for submission.
• Routes clinical / medical-necessity denials with a complete appeal packet, tracks response, and confirms outcome.
• Logs every denial in the central denial log with payer, reason, and root cause; contributes to monthly denial-trend review.
• Reads MCO and commercial-payer provider bulletins, policy updates, and authorization-rule changes as they are published.
• Contributes to the living payer matrix by flagging changes affecting assigned clients or programs.
• Updates SOPs and NetSmart workflow entries in partnership with the Revenue Cycle Manager as payer requirements change.

Benefits

• Medical, dental, and vision coverage with low monthly premiums — no waiting period.
• Competitive PTO policies to support your work-life balance.
• Short- and long-term coverage included.
• 401(k) — 7% Employer Contribution: Employer contributes 7% after your first year with immediate vesting.
• Education assistance for CRCR, Six Sigma, and other professional development.
• Career Growth: Grow into UM leadership, provider relations, or revenue-cycle roles as the function matures.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree