Utilization Management Specialist

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

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