Utilization Management Specialist – Coleman Health Services: Kent, OH

Coleman Health Services is dedicated to serving our communities and positively impacting the lives of our employees and the people they work to serve. As the Utilization Management Specialist, you will evaluate the medical necessity, clinical appropriateness, and efficiency of mental health and substance use disorder treatments. Operating as a critical link between treatment providers and insurance payors, this position secures authorization to maximize reimbursement while ensuring clients receive optimal and appropriate care. This position can be based in any Coleman location, with preference for Kent, OH.

Responsibilities

• Develop and implement processes for obtaining prior authorizations for client care.
• Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
• Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
• Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
• Collaborate with Revenue Cycle Management Director regarding claims payments, denials, and payor-based audits.
• Analyze utilization data and trends to identify opportunities for improving care and reducing non-payment of claims.
• Provide coverage for Compliance Officer during periods of absence.

Requirements

• Bachelor's degree in Social Work, Counseling, Psychology, or Nursing.
• Current relevant State of Ohio professional licensing.
• 5 years of experience in behavioral health or related field.
• Demonstrated knowledge of current and best practices within behavioral health services.
• Demonstrated knowledge of State of Ohio Medicaid Behavioral Health Provider Manual.
• Demonstrated proficiency and experience working on an Electronic Health Record System.
• Demonstrated ability with Windows and Microsoft Office products.
• Exceptional organizational skills and attention to detail.

Preferred Qualifications

• Master's degree in Social Work, Counseling, Psychology, or Nursing.
• 5 years of experience in Utilization Management or Quality Assurance.
• Current certification in Utilization Management, Compliance, or Quality Assurance.
• Demonstrated ability with development of Power BI dashboards and/or SQL.

Benefits

• Health, dental, and vision insurance.
• Accrue three weeks of paid time off during the first year.
• Wellness Reimbursement.
• Ongoing learning and developmental opportunities.

Pay

Starting at $60,000, commensurate with experience.