Utilization Management, Specialist

TheUtilization Management Specialistis a critical member of the Utilization Management team responsible for thetimelyaccurate and clinicallyappropriate managementof referrals authorizations and benefit determinations for capitated and value-based health plan populations.

This role requires a strong understanding of managed careutilizationmanagement payer requirements and healthcare benefits along with the ability to apply clinical guidelines and sound judgment to complex referral and authorization requests. The Utilization Management Specialist partners closely with Medical Directors Care Management leadership providers health plans and internal clinical teams tofacilitateappropriate accessto care while ensuring alignment with organizational policies contractual obligations regulatory requirements and evidence-based medical management guidelines.

The ideal candidate is a highly organized analytical and solutions-oriented healthcare professional who can independently manage competing priorities navigate complex payer requirementsidentifypotential barriers to care and effectively communicate with clinical and operational stakeholders.

Key Responsibilities

UtilizationManagement & Referral Management

• Process referrals authorizations and benefit determinationsin accordance withorganizational policies health plan requirements contractual obligations and applicable regulatory standards.

• Perform comprehensive review of referral requests including eligibility benefit coverage medical necessity criteria network participation and authorization requirements.

• Contact health plans and payer representatives to obtain required authorizations clarify benefits resolve discrepancies andfacilitatetimelyaccess to services.

• ApplyMCG Guidelines organizational medical management criteria CMS coverage determinations and applicable payer-specific policies when evaluating requests.

• Ensure medically necessary services are appropriately authorized within the designated provider network and benefit structure.

• Identifyrequests that do not clearly meet established criteria and appropriately escalate them to the Medical Director for clinical review and determination.

• Support denial and adverse determination processesin accordance withhealth plan requirements organizational policies and applicable regulatory standards.

• Identifypotential gaps barriers or delays in care and proactively escalate issues that mayimpactpatient access or outcomes.

• Email the morning staffing schedule and send to teams

• Create all referrals for the UMC team

• Referral creation of request received is within one day

Clinical & Operational Collaboration

• Partner closely with Medical Directors Care Management leadership Clinical Services providers physicians health plans and other internal stakeholders tofacilitateappropriateandtimelycare.

• Serve as asubject-matterresourceregardingreferral authorizationutilizationmanagement and payer requirements.

• Provide clear and professional communicationregardingauthorization status clinical documentation requirements benefit limitations and next steps.

• Collaborate with providers and clinical teams to obtain necessary clinical documentation and resolve authorization barriers.

• Use critical thinking and problem-solving skills to address complex referral authorization and benefit-related issues.

• Escalate complex high-risk or unresolved issues to the Utilization Management Supervisor or Managerin a timely manner.

Compliance Quality & Reporting

• Maintainaccurate complete andtimelydocumentation within the electronic health record and applicableutilizationmanagement systems.

• Ensure all activities are performedin accordance withHIPAA CMS requirements health plan contracts accreditation standards and applicable state and federal regulations.

• Support internal and external audits bymaintainingaccuratedocumentation and providing requested records and reporting.

• Assistwith health plan reportingutilizationmanagementmetrics quality initiatives and operational performance monitoring.

• Identifyopportunities to improve referral and authorization workflows reduce administrative barriers and enhance operational efficiency.

• Maintain confidentiality and exercise appropriate discretion when handling protected health information and sensitive clinical information.

Communication & Customer Service

• Communicate professionally and effectively with patients providers physicians health plans clinical teams and organizational leadership through telephone email electronic health records and internal communication platforms.

• Providetimelyresolution orappropriate escalationof questions related to referrals authorizations benefits and network requirements.

• Demonstrate professionalism accountability and sound judgment in interactions with internal and external stakeholders.

• Adapt effectively to changing payer requirements regulatory standards organizational priorities and evolving healthcare delivery models.

Knowledge Skills & Abilities

• Strong working knowledge ofutilizationmanagement managed care referral management and prior authorization processes.

• Knowledge of health plan benefit structures provider networkscapitatedarrangements and payer-specific authorization requirements.

• Demonstrated ability to interpret and apply MCG Guidelines CMS coverage policies and medical management criteria.

• Strong understanding of medical terminology healthcare delivery systems and clinical documentation.

• Excellentcritical-thinking analytical problem-solving and decision-making skills.

• Ability to evaluate complex informationidentifygaps and determineappropriate nextsteps.

• Exceptional organizational and prioritization skills with the ability to manage multiple concurrent requests and deadlines.

• Strong written and verbal communication skills with the ability to communicate effectively with both clinical and non-clinical audiences.

• Ability to work independently while functioning effectively within a highly collaborative clinical environment.

• Proficiencywith Microsoft Office electronic health records andutilizationmanagement systems.

• Experience with Epic or another enterprise-level EHR preferred.

• Strong attention to detail and commitment to accuracy compliance andtimelycompletion of work.

• Ability to adapt to changing priorities payer requirements workflows and healthcare regulations.

Education

• Associate degree in Healthcare Administration Nursing Medical Assisting Health Information Management ora relatedhealthcare field preferred.

• Equivalentcombinationof education clinical training and relevant healthcare experience may be considered.

• Additionalcoursework or training inutilizationmanagement medical terminology coding healthcare administration or managed care is preferred.

Required Experience

• Minimum of 2 years ofutilizationmanagement prior authorization referral management or related managed care experience within a health plan medical group IPA ACO capitated organization or healthcare system.

• Demonstrated experience processing referrals and authorizations in a managed care orcapitatedenvironment.

• Experience applying MCG Guidelines or comparable evidence-based medical necessity criteria.

• Experience working directly with health plans and payer representatives.

• Experience reviewing clinical documentation anddeterminingwhether requests meet established criteria.

• Experience collaborating with Medical Directors physicians nurses providers or other clinical stakeholders preferred.

• Medical Assistant care coordination health plan operations or clinical services experience is highly desirable.

Preferred Qualifications

Candidates with any of the following are strongly preferred:

• Experience in value-based care risk-based contracting ACOs IPAs or capitated medical groups.

• Experience working with Medicare Advantage populations and CMS requirements.

• Experience with complex specialty referrals and multi-disciplinary healthcare services.

• Experience supportingutilizationmanagement audits payer audits or regulatory reviews.

• Experience with Epic or other enterprise EHR platforms.

• Experienceidentifyingand implementing process improvements withinutilizationmanagement or clinical operations.

• Certification in healthcare administrationutilizationmanagement coding or a related discipline is a plus.

If you are committed to putting our patients first and helping shape the future of care you belong at Duly.

The compensation for this role includes a base pay range of with the actual $19.07- $28.61 pay determined by factors such as skills experience education certifications geographic location and internal equity. Additional compensation may be available through shift differentials bonuses and other incentives. Base pay is only a portion of the total rewards package.