Demo

Utilization Management Specialist I

Provider Network Solutions
Doral, FL Full Time
POSTED ON 2/12/2025
AVAILABLE BEFORE 4/11/2025

* In office - Not remote *

Position Summary

The Utilization Management Specialist I focuses in the review of prior authorizations and medical records by acting as a liaison between the medical directors and the providers. Coordinates transmission of time sensitive documents in accordance with regulatory compliance and performs regulatory reporting for health plan and internal compliance requirements. The specialist also supports the Utilization Management Director, and Utilization Management Specialist II on Utilization Management ad hoc activities for the department.

Duties and Responsibilities

  • Maintains confidentiality and adheres to contractual and regulatory requirements.
  • Accurately processes prior authorization requests in accordance with member contract provisions, medical policies, departmental policies and procedures and other plan approved guidelines e.g., CMS guidelines, state statutes.
  • Partners with appropriate professionals to ensure strict adherence to the boundaries and timeframes set by regulatory standards, accreditation guidelines, and client contracts.
  • Assists the Utilization Management Specialist II in referring cases to Medical Director when the treatment request does not meet medical necessity guidelines or when a peer-to-peer conversation is necessary to establish medical appropriateness.
  • Establishes knowledge of accreditation and regulatory Utilization Management standards and requirements.
  • Achieves individual productivity and metrics set by Utilization Management Manager.
  • Contributes departmental performance and quality metrics (i.e., regulatory reporting outcomes).
  • Conveys and records authorizations as defined by documentation policies and procedures. Completes all necessary data entry in Medical Management systems and approves or refers to Medical Director potential denials and documents in the Medical Management system per established protocols.
  • Assists the Utilization Management Manager or Director with special projects related to Utilization Management as assigned or directed.
  • Maintains all triage calls related to prior authorizations for the Utilization Management department.
  • Assists the Utilization Management Specialist II with ad hoc responsibilities or duties (referral issues, post service utilization review, and ad hoc TPA processes).
  • Regularly updates departmental workflows and projects on company platforms (e.g., Monday.com).
  • Acts as a liaison between the network and PCPs with referrals for specialist.
  • Maintains organized electronic and hard-copy files of raw data and PI reports.

Knowledge

  • Knowledge of ICD10 codes/CPT codes
  • Intermediate Excel Knowledge
  • Familiar with Authorizations Process
  • Familiar with Utilization Management
  • Research Skills
  • HIPPA Compliant
  • Medical Terminology
  • Healthcare experience in pre-service authorizations and customer service is preferred

Skills

  • Fluent in both English and Spanish; oral and written communication
  • Microsoft (Outlook, Excel, Word, and PowerPoint)
  • Adobe Acrobat
  • Data Entry
  • Excellent written and communication skills
  • Detail oriented and focused on accuracy and efficiency
  • Excellent telephone etiquette.

Job Type: Full-time

Pay: $46,000.00 - $50,000.00 per year

Benefits:

  • 401(k)
  • Dental insurance
  • Disability insurance
  • Flexible spending account
  • Health insurance
  • Health savings account
  • Life insurance
  • Paid time off
  • Tuition reimbursement
  • Vision insurance

Schedule:

  • 8 hour shift
  • Monday to Friday

Experience:

  • Utilization Management: 1 year (Required)

Language:

  • English and Spanish (Required)

Ability to Commute:

  • Doral, FL 33178 (Required)

Work Location: In person

Salary : $46,000 - $50,000

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