Behavioral Health Utilization Analyst (47221) at TCN Behavioral Health Services in TCN Xenia - Xenia, OH 45385

Job description

• Position Type
• Full Time
• Job Shift
• Day
• Travel Percentage
• None
• The Behavioral Health Utilization Analyst is responsible for prior authorization, utilization management, reporting, data tracking, and peer review functions for TCN Behavioral Health Services.

Responsibilities

• Completes and submits prior authorization, reauthorization, continued-stay, and additional-unit requests for mental health and substance use disorder services.
• Reviews clinical documentation to determine whether it supports the clinician’s recommended service or level of care and meets applicable medical necessity criteria and payer requirements.
• Reviews assessments, diagnoses, treatment recommendations, individualized service plans, ASAM dimensions, risk ratings, treatment history, client progress, functional needs, UDS results, and continued-stay information when applicable.
• Identifies missing, unclear, inconsistent, or incomplete information and follows up with the appropriate clinical staff before submitting the request.
• Assists staff with documentation and workflow needs related to authorization processes.
• Completes payer forms and prepares authorization narratives and medical necessity summaries using information documented by the treatment team.
• Submits required information through payer portals, fax, email, or other payer-required methods.
• Responds to payer requests for additional information and follows authorization requests through final determination.
• Communicates approvals, partial approvals, denials, authorized service dates, approved units, and other payer decisions to the appropriate staff.
• Assists with reconsiderations, peer-to-peer reviews, and appeals by organizing denial information, medical necessity concerns, clinical indicators, and supporting documentation.
• Maintains centralized tracking of authorization start and end dates, requested and approved units, reauthorization deadlines, service limits, payer outcomes, and follow-up needs.
• Identifies trends in authorization outcomes, payer behavior, documentation quality, and utilization patterns.
• Monitors utilization and identifies clients approaching authorization expiration dates, payer limits, or reauthorization thresholds.
• Works closely with clinical staff, supervisors, billing, MIS, leadership, and external payers to support utilization management functions.
• Identifies authorization gaps, unused units, overages, missed deadlines, and services provided outside approved dates.
• Works with clinical, program, and billing staff to resolve authorization concerns that may affect service delivery, claims, reimbursement, or continuation of care.
• Monitors Medicaid, managed care, commercial insurance, fee-for-service, and other payer requirements and communicates changes to affected staff.
• Coordinates peer review assignments, schedules, instructions, completion tracking, findings, and follow-up.
• Ability to effectively train and coach staff regarding authorization, documentation, and reporting processes.
• Participates in the development and delivery of New Hire Orientation presentations and other staff training as assigned (i.e. ISP, authorizations).
• Attends department meetings, staff meetings, program meetings, committees, and workgroups to provide updates, review trends, discuss concerns, and support communication between departments.
• Tracks and completes follow-up items resulting from payer decisions, authorization reviews, reports, peer reviews, training, and meetings.
• Participates in quality improvement activities by identifying trends, workflow concerns, documentation issues, and opportunities for process improvement.
• Maintains accurate and organized records of authorization activity, utilization, reporting data, peer review activity, training, and follow-up.
• Maintains confidentiality of client information and completes work in accordance with HIPAA, agency policy, payer requirements, and applicable state and federal regulations.
• Communicates professionally with staff, supervisors, leadership, payers, and external partners.
• Maintains a positive public image for TCN by interacting with clients, employees, business contacts, vendors, and the community with courtesy and respect.
• Performs other job duties as assigned.
• Develop, maintain, and distribute routine and ad hoc reports related to utilization, authorizations, denials, payer trends, peer reviews, documentation concerns, and program performance.
• Collect, validate, analyze, and summarize data used for leadership reporting, program monitoring, quality improvement, and utilization management activities.
• Create and maintain dashboards, spreadsheets, authorization trackers, templates, calendars, and other reporting tools.
• Support database management, SQL reporting, report testing, data validation, and related information systems functions.
• Reconcile information across electronic health records, payer portals, billing systems, and internal tracking tools to identify and resolve discrepancies.
• Collaborate with MIS, billing, and program leadership to improve reporting processes, data integrity, and workflow efficiency.
• Participates in process improvement activities through workflow analysis, procedure development, reporting review, and identification of operational improvement opportunities.

Requirements

• Education: Associate degree required. Bachelor’s degree in healthcare administration, human services, behavioral health, business administration, data analytics, or a related field preferred. Candidates currently enrolled in a related bachelor’s degree program may be considered. Comparable education and experience may also be considered.
• Experience:
• Other: Must have strong attention to detail, the ability to manage multiple responsibilities and deadlines, and the ability to communicate clearly with clinical staff, supervisors, leadership, billing, MIS, and external payers.
• Behavioral health, substance use disorder treatment, healthcare administration, utilization management, prior authorization, billing, case management, clinical documentation review, data management, or reporting preferred.
• Experience working with Medicaid, managed care organizations, commercial insurance, payer portals, prior authorization forms, medical necessity requirements, and healthcare documentation preferred.
• Experience creating reports, maintaining tracking systems, organizing and validating data, using spreadsheets, reviewing trends, and supporting workflow development preferred.
• Experience with electronic health records, database tools, SQL-based reporting, dashboards, or report-writing software preferred.
• Certification: CDCA or other applicable behavioral health credential preferred.

Skills

Required

• Strong attention to detail

Preferred

• Database tools
• SQL-based reporting
• Dashboards
• Report-writing software