UR Coordinator

We're seeking a meticulous UR Coordinator with a strong working knowledge of medical necessity criteria for Spravato and TMS services, including familiarity with CMS, commercial payer, and MassHealth guidelines.

We are seeking a detail-oriented and highly knowledgeable UR Coordinator to join our team and manage the client insurance authorization processes. As a key team member, you will ensure timely submission of required clinical information and documentation, including medical necessity letters, progress notes, rating scales, and treatment plans. You will also work cross-functionally to coordinate with providers, clinical staff, and billing teams to ensure complete and accurate information is submitted in a timely manner. You will be organized and thorough by frequently tracking and following up on authorization requests, denials, appeals, and renewal.

What You Will Do

• Obtain and manage prior authorizations for Spravato and TMS services from commercial and government insurance plans
• Ensure timely submission of required clinical documentation, including medical necessity letters, progress notes, rating scales, and treatment plans
• Review payer-specific medical policies to determine criteria for Spravato and TMS coverage
• Coordinate with providers, clinical staff, and billing teams to ensure complete and accurate information is submitted
• Frequently tracking and following up on authorization requests, denials, appeals, and renewals
• Maintain detailed records of payer communication, submission timelines, and authorizations received
• Provide support to new customers who are in their start-up phase by navigating authorization processes and clinical documentation.
• Stay current on changes in insurance requirements, payer policies, and clinical documentation standards
• Take on additional projects and tasks as assigned.

What it Takes to Join the Family

• Minimum 2 years of experience in medical prior authorization, utilization review, or billing, preferably in behavioral health or neuromodulation
• Strong working knowledge of medical necessity criteria for Spravato and TMS services, including familiarity with CMS, commercial payer, and MassHealth guidelines
• Experience with a wide range of insurance carriers, including Massachusetts and Rhode Island-specific carriers.
• Comfortable working with EHR systems, payer portals, and medical documentation
• Exceptionally organized, with proven ability to manage multiple priorities and tight deadlines
• Detailed and organized communication skills, both written and verbal
• Ability to work independently and collaboratively with clinical and administrative staff
• Preferred experience with in-network and out-of-network authorization workflows
• Preferred prior work with REMS-certified treatment programs