Utilization Management Specialist

This is a fully remote position, open to applicants in Arizona, +7 more states.

📋 Description

• Oversee a designated portfolio of cases in collaboration with UR Nurses to facilitate timely utilization review processes.

• Prepare and organize clinical review packets along with necessary documentation for submission to payers.

• Examine records to ensure all required documentation elements are included and report any gaps to the assigned UR Nurse.

• Track submission confirmations and follow up on outstanding payer determinations.

• Manage the lifecycle of authorizations, which includes entry, tracking, follow-up, documentation of decisions, and monitoring payer response timelines.

• Regularly check payer portals and reach out to payers for updates on authorizations and to resolve discrepancies in status.

• Prioritize cases according to submission deadlines, authorization expiration risks, and regulatory time constraints.

• Raise urgent authorization concerns, delays, or obstacles that could lead to unnecessary denials or lapses in authorization.

• Coordinate the logistics for peer-to-peer scheduling and maintain associated documentation.

• Record and convey payer determinations in EPIC/CS-Link following departmental and regulatory standards.

• Identify and report systemic issues in the authorization workflow to UM leadership.

• Ensure accurate entry of required documentation into EPIC/CS-Link.

• Engage with both internal and external partners to keep patient and authorization information updated and comprehensive.

⛳️ Requirements

• A high school diploma or GED is mandatory.

• An associate's degree or college diploma in business, health, or a related discipline is preferred.

• A minimum of 2 years of experience in hospital authorization management, utilization review support, revenue cycle operations, or payer communication processes is required.

• Experience in independently managing authorization workflows is highly regarded.

• A minimum of 2 years of acute care experience is preferred.

• Approved remote states include: Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, Texas.

🏝️ Benefits

• Health care coverage.

• Paid time off.

• 403(B) retirement plan.

• Health and dental insurance.

• Competitive salary packages.

• An inclusive work environment that is culturally and ethnically diverse.