Utilization Management Specialist

University of California - Los Angeles Health
United States, California, Los Angeles
Dec 28, 2024
Description Under 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 job Salary Range: $30.56 - $60.82 Hourly Qualifications Required Qualifications: Bachelor's degree in healthcare administration, or a related field or a combination of equivalent education, experience, and training Minimum three years of experience in utilization management, care coordination, or a similar role within a healthcare setting Experience processing ambulatory commercial, Medicare Fee for Service, Medicare Advantage prior authorizations Working knowledge of HMO referral process, eligibility verification, and health plan benefit interpretation Strong understanding of healthcare networks, referral processes, and out-of-network utilization strategies Demonstrated data analytical skills Strong organizational, data analytical, and problem-solving skills and proficient in MS Excel Team orientation and ability to work effectively across functional areas of the company Ability to work independently utilizing company established processes Preferred Qualifications: Provider contracting experience Minimum three years of experience working in a Managed Care environment Experience reviewing and understanding Commercial and Medicare benefits and COB determination, DOFR interpretation and the application of Medicare Guidelines