Utilization Review and Billing Coordinator

Job description

Who We Are: Prosperous Health San Diego is a beacon of hope and transformation, offering comprehensive outpatient treatment services for mental health and substance use disorders. Situated in a supportive and inclusive environment, we welcome individuals from all walks of life, guiding them toward sustainable recovery and reintegration into society. Our programs are rooted in a holistic philosophy, addressing every client's mental, physical, and emotional well-being. From evidence-based therapies and wellness initiatives to individualized support, we are committed to fostering resilience and renewal in all we serve. Our purpose at Prosperous Health San Diego is to inspire lasting transformation by providing compassionate care and structured programs that empower individuals to overcome the challenges of addiction and mental health conditions. Through personalized treatment plans, evidence-based therapies, and a wide range of support services, we equip clients with essential life skills, promote relapse prevention, and nurture personal growth, paving the way for a brighter future grounded in empowerment and well-being. Mission Statement: Our mission at Prosperous Health San Diego is to transform lives by offering exceptional mental health and substance use disorder services within a compassionate and inclusive environment. Through cutting-edge treatment pathways and holistic care, we aim to inspire hope, resilience, and sustainable recovery for every individual we serve. Vision for the Future: Looking ahead, Prosperous Health San Diego envisions a world where recovery is celebrated as a transformative journey and holistic well-being is accessible to all. We strive to evolve and expand our services continuously, maintaining the highest standards of care while adapting to the dynamic needs of our clients. Our vision is to lead the way in mental health and addiction recovery, fostering a community where individuals can thrive and achieve independence. Company Values: At Prosperous Health San Diego, our core values—compassion, integrity, innovation, inclusivity, and collaboration—serve as the foundation of our work. We are dedicated to empowering individuals, holding ourselves accountable to the highest ethical standards, and embracing diversity in all its forms. Our commitment to innovation drives us to explore new methods and technologies, ensuring the best possible outcomes for our clients. By fostering meaningful connections within our community, we create a ripple effect of positive change, rebuilding lives and inspiring hope far beyond our doors. Position Title: Utilization Review and Billing Coordinator Employment Status: Full-Time Classification: Non-Exempt Salary Range: $29 – $35 per hour, BOE Supervisor: Chief Executive Officer Benefits Package: Comprehensive benefits package including health insurance, dental and vision coverage, life insurance, retirement plan options, Paid Time Off (PTO), and opportunities for professional development. Summary of Major Responsibilities The Utilization Review and Billing Coordinator owns the full revenue cycle for Prosperous Health San Diego’s outpatient Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) serving clients with mental health and substance use disorders. This role is responsible for verification of benefits, initial and concurrent authorizations, utilization review coordination with the clinical team, quality assurance of clinical and billing files, facility census tracking, accurate coding and claims submission, accounts receivable follow-up, denial management, and appeals. The Coordinator partners closely with admissions, clinical, and leadership teams to protect revenue integrity, ensure medical necessity documentation supports payer requirements, and maintain compliance with HIPAA, payer contracts, and organizational standards—while upholding the mission of compassionate, high-quality care. Detailed Duty Statement Complete Verification of Benefits (VOB) for prospective and active clients using insurance online portals and telephone outreach to carriers; document eligibility, coverage limits, copays, deductibles, coinsurance, out-of-pocket maximums, and behavioral health-specific benefits with accuracy and timeliness. Interpret eligibility and benefits information and clearly communicate relevant coverage details to admissions, clinical, administrative, and leadership staff to support informed intake and treatment planning decisions. Obtain, track, and manage initial and concurrent authorizations for PHP and IOP levels of care; coordinate with the treatment team to secure clinical documentation that supports medical necessity standards (including ASAM-informed criteria where applicable). Lead utilization review processes, including payer communication for concurrent review, authorization extensions, and medical necessity inquiries; escalate barriers promptly and document all UR activity thoroughly. Perform quality assurance reviews of clinical and billing files for completeness, accuracy, and compliance prior to and throughout the billing cycle; partner with clinicians to remediate documentation gaps that could impact authorization or reimbursement. Maintain accurate facility census tracking and related operational reports, ensuring census data aligns with authorization status, level of care, and billing readiness. Capture charges, apply appropriate behavioral health coding (CPT, HCPCS, ICD-10), and create and submit clean claims in accordance with payer requirements and PHP/IOP billing practices. Support payment posting and reconciliation processes as applicable; identify discrepancies and coordinate resolution with finance/leadership. Conduct proactive claims follow-up and accounts receivable management, including denial management, underpayment identification, and timely resubmission of corrected claims. Prepare and submit appeals with supporting clinical and administrative documentation; track appeal outcomes and incorporate payer feedback into process improvements. Maintain payer relationships and manage insurance portals, credentials, and electronic workflows to ensure continuous access and efficient processing. Generate and deliver regular reporting to leadership on census, authorization status, A/R aging, denial trends, and revenue cycle performance metrics; recommend process improvements based on data. Uphold HIPAA, payer contract, and organizational compliance standards in all revenue cycle activities; protect client confidentiality and maintain audit-ready records. Collaborate effectively with admissions, clinical, administrative, and leadership teams to support seamless client financial clearance, continuity of care operations, and organizational goals. And other duties as assigned. Qualifications Needed Required: 3–5 years of experience in utilization review, medical billing, and/or revenue cycle management; experience in behavioral health, mental health, and/or substance use disorder treatment strongly preferred (outpatient PHP/IOP experience highly preferred). High school diploma or equivalent required; associate’s or bachelor’s degree preferred. Demonstrated knowledge of commercial insurance Verification of Benefits, prior authorization, concurrent review, and medical necessity standards; familiarity with ASAM criteria a plus. Experience with behavioral health billing and coding (CPT, HCPCS, ICD-10), including knowledge of PHP/IOP billing practices preferred. Proven experience with claims submission, denial management, appeals, and accounts receivable follow-up. Proficiency with electronic health record (EHR) systems and clearinghouse/billing platforms. Strong telephone and written communication skills for effective interaction with insurance carriers, clinical staff, and internal stakeholders. Exceptional attention to detail, organizational skills, and ability to manage multi-payer workflows, census tracking, and chart readiness for UR and billing. Commitment to HIPAA compliance, ethical revenue cycle practices, and professional integrity. Ability to work collaboratively in a mission-driven outpatient behavioral health setting. Preferred: Professional credential such as CPC, CPB, CCS, or equivalent billing/coding certification. Utilization review experience with California commercial plans (e.g., Cigna/Evernorth, Aetna, and other commercial payers). Prior experience in a Joint Commission–accredited behavioral health organization. The Utilization Review and Billing Coordinator at Prosperous Health San Diego: The ideal Utilization Review and Billing Coordinator is a detail-driven, relationship-oriented professional who thrives at the intersection of clinical operations and revenue integrity. You bring calm precision to complex payer workflows, advocate for clients by securing timely authorizations, and partner with the clinical team so documentation truly reflects the care being delivered. You take ownership of the full revenue cycle—from first VOB call through clean claim, payment, and appeal—while never losing sight of the people behind every account. If you are motivated by accurate, ethical billing that sustains exceptional outpatient mental health and substance use disorder care, and you want your work to support lasting transformation in the lives we serve, we invite you to join Prosperous Health San Diego.