The Utilization Management Specialist is a critical member of the Utilization Management team, responsible for the timely, accurate, and clinically appropriate management of referrals, authorizations, and benefit determinations for capitated and value-based health plan populations.
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.
- Process referrals, authorizations, and benefit determinations in accordance with organizational 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, and facilitate timely access to services.
- Apply MCG 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.
- Associate degree in Healthcare Administration
- Associate degree in Nursing
- Associate degree in Medical Assisting
- Associate degree in Health Information Management
- Nice to have: Value-based care
- Comprehensive medical, dental, and vision benefits
- Healthcare navigation assistance
- Mental health benefit at no cost
- Employer provided life and disability insurance
- $5,250 Tuition Reimbursement per year