Utilization Review & Authorization Coordinator - Teen IOP/PHP

Utilization Review & Prior Authorization Coordinator Remote | Contract / Part-Time to Full-Time | Adolescent Behavioral Health | NC Commercial Payers | Expert Level ABOUT THE ORGANIZATION We provide Intensive Outpatient (IOP) and Partial Hospitalization (PHP) programming for adolescents ages 10–17 in Apex, NC. We contract with BCBS NC, UnitedHealthcare/Optum, Aetna, and Cigna/Evernorth, and operate Ritten EMR with Availity and Waystar for authorizations and revenue cycle. Our team is small, fast-moving, and focused on making sure no clinically appropriate admission is lost to a process failure. THE ROLE We need a sharp, self-directed UR/PA Coordinator who can own the authorization pipeline end-to-end — from initial submission through appeals — across our IOP and PHP service lines. This is not a data-entry role. You will work directly with our clinical and billing teams to ensure every active client has a valid, current authorization, and that no clinically appropriate admission is lost to a process failure. CORE RESPONSIBILITIES • Submit initial prior authorization requests for IOP and PHP admissions across BCBS NC, UHC/Optum, Aetna, and Cigna/Evernorth in a timely manner • Conduct concurrent review submissions at required intervals; document clinical justification aligned to medical necessity criteria and payer-specific guidelines • Track authorization status in Waystar and our internal authorization log; flag gaps and expiring auths proactively • Coordinate peer-to-peer calls between our Clinical Director and payer Medical Directors when initial requests are denied • Prepare and submit Level I and Level II appeals with supporting clinical documentation; maintain denial reason tracking • Liaise with Ritten EMR to ensure documentation supports authorization requests (treatment plans, group notes, assessments) • Communicate authorization updates to the clinical team and update Ritten accordingly • Maintain compliance with all HIPAA privacy and security standards in every communication and workflow • Generate weekly UR dashboard reports: auth approval rates, average turnaround time, denial rates by payer, and outstanding appeals REQUIREMENTS Non-Negotiable • Minimum 2 years of UR/PA experience in behavioral health • Demonstrated experience working with commercial payers (BCBS, UHC/Optum, Aetna, or Cigna) — NC experience a plus • Working knowledge of medical necessity criteria for adolescent IOP/PHP levels of care • Proven ability to write clinical justification narratives that win authorizations and appeals • Comfortable operating independently in a remote environment with minimal supervision Preferred Qualifications • Experience in Ritten EMR • Waystar / RCM platform familiarity • Availity portal proficiency • CPUR, CPHQ, or similar certification • Background in adolescent behavioral health or IOP/PHP clinical operations • Strong Google Sheets / Excel skills • Familiarity with ICD-10 and H-code billing WORKING EXPECTATIONS • Availability: Must be reachable during core hours (8AM – 5PM ET, Mon–Fri) for time-sensitive auth requests and peer-to-peer coordination • Turnaround: Initial authorization submissions completed within 24 hours of referral; concurrent reviews submitted no later than 48 hours before current auth expiration • Communication: Weekly status update via our internal platform; escalation of urgent denials within 2 business hours • Tools: Must have reliable internet, HIPAA-compliant workstation, and ability to access web-based portals (Ritten, Waystar, Availity, payer portals) • BAA: Must be willing to sign a Business Associate Agreement prior to start HOW TO APPLY Submit a proposal that directly addresses the following. Generic cover letters will not be reviewed. 1. Describe your experience submitting prior authorizations for IOP or PHP programs — which payers, what volume, and what your approval rate was. 2. Walk us through how you handle a concurrent review denial from a payer. What is your process? 3. Have you worked with Ritten or Availaty, Waystar? If so, describe specifically how you used each platform in a UR context. 4. What does your current availability look like, and how many active clients or accounts can you manage simultaneously?