Psych-Pre-cert Specialist

• Obtains pre-certifications for psychiatric-specific services
• Verifies behavioral health coverage for various payers including Medicaid Medicare Advantage and commercial insurance plans
• Applies InterQual and MCG behavioral health criteria tovalidatemedical necessity using psychiatric evaluations and treatment plans
• Advocates with insurance providers to secure approval for psychiatric admissions

• Documents all pre-certification activities and authorization decisions in systems
• Utilizes psychiatric ICD-10 codes and CPT codes appropriately
• Maintainsaccuraterecords of all pre-certification requests approvals and denials
• Tracks authorization status and updates required systemsin a timely manner

• Collaborates with psychiatrists crisis team members andutilizationcoordinators on urgent authorization needs
• Communicates pre-certification status and next steps toappropriate teammembers
• Participates in team discussionsregardingauthorization requirements and payer trends
• Escalates complex or urgent cases to supervisorimmediately

• Assists Utilization Coordinators with:

1. Psych concurrent review tracking
2. Entering authorization updates in UR systems
3. Preparing simple appeal documentation
4. Researching payer policies for behavioral health coverage

• Provides backup support for UR tasks as needed
• Ensures smooth handoff between pre-certification and concurrent review processes

• Monitors and responds to incoming calls from payers providers and internal departmentsin a timely manner
• Processes incoming faxes related to authorizations throughout the day
• Ensures no voicemail or fax goes unaddressed beyond 24 hours
• Escalates urgent issues to supervisorimmediately

• Maintains knowledge of behavioral health insurance guidelines for Medicaid Medicare Advantage and commercial plans
• Understands and applies psychiatric terminology DSM-5 diagnoses levels of care and ASAM criteria for SUD treatment
• Ensures compliance with mental health parity laws and HIPAA regulations
• Maintains confidentiality of all patient information

• High School Diplomarequired
• Associate or Bachelors degree in healthcare administration Psychology Social Work or related field preferred
• Relevant experience may be considered in lieu of degree

1. Behavioral health pre-certification
2. Psychiatricutilizationreview
3. Psychiatric billing or authorizations

• Experience with behavioral health insurance guidelines (Medicaid/Medicare Advantage commercial plans)required
• Familiarity with psychiatric terminology DSM-5 levels of care and ASAM criteria for SUDrequired

• Experience with psych EMRs (Cerner preferred)
• Knowledge of Illinois Medicaid managed care plans preferred
• De-escalation skills for high-stakes insurer negotiations preferred

• Working knowledge of behavioral health insurance guidelines and authorization processes
• Understanding of psychiatric diagnoses levels of care and treatment modalities
• Familiarity with InterQual/MCG criteria for behavioral health
• Knowledge of mental health parity laws and HIPAA requirements

• Strong organizational skills and attention to detail
• Excellent verbal and written communication skills for interacting with payers and clinical teams
• Ability to advocate effectively with insurance providers
• Proficiencywith electronic medical records (Cerner preferred) and Microsoft Office (Outlook Excel Word)
• Critical thinking and problem-solving abilities
• Ability to prioritize multiple tasks and respond to time-sensitive requests

• Ability to work independently and manage own caseload
• Capacity to remain focused despite frequent interruptions (calls emails faxes)
• Ability to collaborate effectively with psychiatrists crisis teams andutilizationcoordinators
• Flexibility to adapt to changing payer requirements and priorities
• Commitment to accuracy and thorough documentation
• Ability tomaintainprofessionalism during high-stakes insurer negotiations

• Full-time position Monday-Friday with potential for occasional extended hours based on patient needs
• Work is performed in an office setting within a hospital environment
• May require sitting for extended periods while completing computer-based tasks
• Frequent telephone and computer use
• Regular collaboration with clinical teams and external payers

• Paid Sick Time - effective 90 days after employment
• Paid Vacation Time - effective 90 days after employment
• Health vision & dental benefits - eligible at 30 days following the 1st of the following month
• Short and long-term disability and basic life insurance - after 30 days of employment

Required Experience:

IC