Utilization Management Support Specialist - Case Management Utilization Review

Job Requirements

POSITION SUMMARY

The Utilization Management Support Specialist provides administrative and operational support to the Utilization Management (UM) team to ensure timely, accurate, and efficient utilization review processes. The Utilization Management Support Specialist supports prior authorization tracking, denial management, peer-to-peer coordination, documentation management, and communication with payers, providers, and internal clinical staff. The Utilization Management Support Specialist is non-clinical and functions as a critical liaison to support regulatory compliance, workflow efficiency, and optimal patient throughput.

PRIMARY ACCOUNTABILITIES

Assists UM nurses and case managers with authorization and concurrent review tracking; monitoring authorization status and following up with payers as needed. Maintain accurate authorization and review logs within the Electronic Medical Record (EMR) and UM systems. Ensures required clinical documentation is received, uploaded, and routed appropriately. Scans, uploads, and indexes documents into the EMR system, as well as, maintaining UM databases, spreadsheets, and tracking tools. Tracks denials, peer-to-peer requests, and appeal deadlines; coordinates peer-to-peer scheduling between physicians and payer, and Aids with compiling appeal packets and required documentation. Verifies denial letters and payer correspondence are routed to appropriate UM staff. Aids with compiling appeal packets and required documentation. Serve as a point of contact for payer inquiries, provider offices, and internal departments. Communicate authorization outcomes to clinical teams and ancillary departments. Maintain professional and timely communication via phone, secure email, and e-fax, as well as, managing UM e-fax lines, phone queues, and shared inboxes. Assist with data collection for UM metrics (e.g., authorization turnaround times, denial volumes). Support audits and regulatory reviews as requested; and with scheduling meetings, maintaining policies, and supporting departmental projects. Work Experience

MINIMUM QUALIFICATIONS

Education:

High School Diploma or equivalent.

Work Experience:

One (1) year in healthcare administrative experience.

Licensure:

None Certification:

None Skills/Knowledge/Abilities:

Proficient in Microsoft Office- Outlook, Word, Excel. Ability to work autonomously with minimal supervision. Strong critical thinking skills. Strong organizational, communication, and time-management skills. Ability to manage multiple priorities and deadlines in a fast-paced environment. Ability to maintain composure in a stressful office environment. Able to work flexible hours and days, including weekends, to meet departmental needs.

PREFERRED QUALIFICATIONS

Education:

Associate's degree.

Work Experience:

Two (2) years' experience in; Utilization Management, Case Management, Revenue Cycle, Prior Authorization, or Medical Office Operations. One year of customer service experience working in a face-to-face environment. Prior experience in hospital UM, managed care, or insurance environment.

PHYSICAL REQUIREMENTS

Majority of time involves sitting or standing; occasional walking, bending, and stooping. Long periods of computer time or at workstation. Light work that may include lifting or moving objects up to 20 pounds with or without assistance. May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. Communicating with others to exchange information. Visual acuity and hand-eye coordination to perform tasks. Workspace may vary from open to confined. May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle. Benefits

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule :

Full-Time Shift Times :

800am430pm

Paygrade :

PG-PG-24