Utilization Management Specialist

Position Summary

The Utilization Management Specialist plays a key role in optimizing healthcare resource utilization and ensuring adherence to quality and compliance standards. This specialist-level position involves expertise in reviewing healthcare service requests, including prior authorizations, inpatient services, denials, and appeals. The role implements utilization management strategies while collaborating closely with internal and external stakeholders to drive operational excellence and improve patient outcomes.

Essential Position Functions/Responsibilities

• Provide non-clinical support to ensure policies and procedures promote the appropriate level of care or services for members.
• Lead cross-training initiatives, cultivating a versatile team capable of handling Prior Authorization, Inpatient reviews, Denials, and Appeals.
• Conduct comprehensive reviews, including prior authorizations, concurrent, and retrospective reviews.
• Apply advanced utilization management principles and industry guidelines to assess the appropriateness and efficiency of requested healthcare services.
• Engage daily with healthcare providers and members to gather clinical operational information and maintain communication throughout the review process.
• Review daily utilization management (UM) reports to track and manage service requests.
• Assess the necessity of requested services based on established guidelines, criteria, and benefit plans.
• Communicate authorization decisions clearly and promptly to healthcare providers and members.
• Provide alternate coverage for denials, appeals, and inpatient processes, ensuring continuity of services during critical situations.
• Process delegated appeals for denied services, ensuring timely submission, documentation, and regulatory compliance.
• Identify and forward standard or expedited appeals to the appropriate health plan.
• Ensure compliance with all timeframes and regulatory standards, maintaining accuracy in processing.
• Prepare, document, and route cases in the appropriate system for clinical review, ensuring completeness and timeliness.
• Issue written or electronic notifications for all denied services, ensuring clarity and adherence to regulatory requirements.
• Differentiate denials by Health Plan, Line of Business, and type of service, ensuring accurate communication with appropriate documentation inserts.
• Verify and document member language preferences to ensure effective communication and compliance with language access standards.
• Demonstrate proficiency in NCQA guidelines, ensuring organizational compliance with quality standards.
• Assist in quality improvement initiatives aimed at enhancing service delivery and care coordination.
• Collaborate with internal teams (claims, customer service, provider relations) to ensure coordinated care and efficient service delivery.
• Provide guidance to internal teams on utilization management principles, policies, and procedures.
• Assist in the development and implementation of utilization management strategies to enhance operational efficiency and quality of care.
• Conduct audits to ensure compliance with utilization management policies and procedures.
• Monitor and analyze utilization review outcomes, identify trends, and recommend process improvements.
• Stay current on industry regulations, guidelines, and best practices related to utilization management and review.
• Perform other duties as assigned to support operational goals.

Qualification Requirements

• Skills, Knowledge, Abilities:
• Professional demeanor with a strong ability to excel in a team-oriented environment.
• In-depth experience with utilization review and prior authorization processes, preferably within a managed care organization.
• Proficient in medical terminology and ICD-10 codes.
• Strong proficiency in MS Office programs (Word, Excel, Outlook, Access, and PowerPoint).
• High level of accuracy and attention to detail, with strong analytical abilities.
• Excellent communication and organizational skills, with the ability to manage time effectively and meet deadlines.
• Ability to adapt to changing environments and processes.
• Desire and ability to work successfully in a small company setting.
• Training/Education:
• Associate’s degree in healthcare administration or relevant work experience is required.
• Bachelor’s degree in healthcare administration is preferred.
• Experience:
• 5+ years of experience in managed care, specifically in utilization management.
• 5+ years of customer service and patient-facing experience.
• 3+ years of working knowledge of outpatient/inpatient services and regulatory guidelines.

Benefits

Base Compensation: $65,000 - $75,000 ($31-$36 per hour)

Bonus Incentive: Eligibility based off organizational performance

Benefits: Fully paid Medical & Dental employee coverage + robust benefits package (PTO, 401k, FSA, Tuition Reimbursement, etc.)

Equal Employment Opportunity Statement

HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Department

Clinical Services

Employment Type

This is a non-management position

Work Hours

This is a full time position

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