What are the responsibilities and job description for the Utilization Management Specialist position at UCLA Health?
DescriptionUnder the direction and supervision of the Utilization Management Manager, the Utilization Management Specialist is responsible for overseeing the research, resolution and workflow development of out-of-network (OON) referral requests. This role reviews OON referral requests from members and providers, acting as a key liaison to facilitate timely, accurate, and efficient processing. In addition, the UM Specialist will :
- Ensure compliance with organizational guidelines and regulatory standards, promoting quality care access for members while optimizing network utilization and reducing unnecessary out-of-network expenses
- Collaborate closely with the network team to identify gaps in provider availability and propose suggestions for network expansion
- Be responsible for analyzing OON utilization data and developing trend reports that assist the network team with network gap closures
- Be able to work under general supervision, relying on instructions, work process guidelines, policies & procedures, and departmental company knowledge / experience to perform the functions of the jobSalary Range : $30.56 - $60.82 HourlyQualificationsRequired Qualifications : Bachelor's degree in healthcare administration, or a related field or a combination of equivalent education, experience, and trainingMinimum three years of experience in utilization management, care coordination, or a similar role within a healthcare settingExperience processing ambulatory commercial, Medicare Fee for Service, Medicare Advantage prior authorizationsWorking knowledge of HMO referral process, eligibility verification, and health plan benefit interpretationStrong understanding of healthcare networks, referral processes, and out-of-network utilization strategiesDemonstrated data analytical skillsStrong organizational, data analytical, and problem-solving skills and proficient in MS ExcelTeam orientation and ability to work effectively across functional areas of the companyAbility to work independently utilizing company established processesPreferred Qualifications : Provider contracting experienceMinimum three years of experience working in a Managed Care environmentExperience reviewing and understanding Commercial and Medicare benefits and COB determination, DOFR interpretation and the application of Medicare GuidelinesUCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person’s unique achievements and experiences to further set us apart.
Salary : $31 - $61
