Specialist, UM Administrative

About the role

OhioGuidestone provides a complete continuum of responsive person-centered prevention services, mental health and substance use treatment, and wrap-around supports, serving the needs of over 50,000 people each year through telehealth and locations across Ohio. At OhioGuidestone, we believe a workforce comprised of employees from diverse backgrounds and communities and a culture of belonging makes us a better organization. Together, we continue to build a workplace that encourages, supports, and celebrates the varied voices of our employees.

Responsibilities

• Demonstrate the values and guiding principles of OhioGuidestone every day, performing with the highest standards of excellence, integrity and ethics.
• Provide administrative and operational support to the Billing department.
• Receive, review, and route authorization and utilization management requests to the appropriate department or clinical reviewer.
• Verify member, provider, authorization, and service information for completeness and accuracy.
• Enter and maintain authorization and related information in designated internal systems.
• Monitor requests and cases to ensure required information is obtained and established deadlines are met.
• Request missing documentation from provider offices, health plan staff, and/or internal departments.
• Communicate with providers, members, health plan staff, and internal teams regarding administrative aspects of authorization requests.
• Track pending, approved, denied, and incomplete requests and provide appropriate follow-up.
• Maintain accurate records and documentation in accordance with department procedures, organizational policies, and applicable regulatory requirements.
• Prepare reports, spreadsheets, and status updates related to Utilization Management activities.
• Identify administrative issues, discrepancies, missing information, or delays and escalate concerns appropriately.
• Follow established workflows, policies, regulatory requirements, and confidentiality standards.
• Assist clinical reviewers and department leadership with administrative tasks, projects, and other duties as assigned.
• Maintain productivity, accuracy, and quality standards established by the department.
• Exhibit positivity, flexibility and a willingness to take on new responsibilities as requested or required.
• Demonstrate positive leadership, promote a team-based work environment and a culture of belonging.
• Present the Agency in the most positive light with all internal and external contacts.

Requirements

• High School Diploma or GED required.
• Associate or bachelor's degree preferred.
• 1–3 years of experience in healthcare administration, insurance, medical office operations, prior authorization, claims, utilization management, or a related field preferred.
• Experience with electronic medical records, health plan, authorization, or case-management systems preferred.

Qualifications

• Mission driven; strong desire to make an impact.
• Proficient with technology, including dispatch systems, electronic health records (EHRs), and Microsoft Office Suite.
• Ability to work both independently and collaboratively within a fast-paced environment.
• Effective interpersonal skills; able to speak effectively with individuals and/or groups of people.
• Flexible; able to work days, evenings, and/or weekends, as desired to meet the needs of clients.