Utilization Management Peer-to-Peer Specialist

Job Type


Full-time

Description

Job Classification:

• This is an exempt position under the Fair Labor Standards Act (FLSA) and is not eligible for overtime pay.

Our Mission:

Our mission is to drive financial wellness in healthcare organizations so more patients can receive the care they need.

Our Vision:

Our vision is a future where we help healthcare organizations thrive in a complex ecosystem by clearing a path to financial health.

Our Culture:

We are committed to creating a workplace where every member feels valued, empowered, and inspired to contribute their best. Together we will foster a culture that promotes work-life balance and celebrates community engagement, personal achievements, milestones, and special occasions.

Values:

Integrity - We do what's right, no matter what.

Innovation - We use a harmonious blend of data, tech, and a human-centric approach.

Compassion - We understand the stress of healthcare organizations and their patients.

Determination - Our mission is our guiding force.

Partnership - We build enduring relationships through listening, communication and accountability.

Dignity - We have significant pride in each other and our work.

Job Summary: The Peer-to-Peer Specialist is responsible for managing all aspects of insurance peer-to-peer (P2P) meeting scheduling workflow between healthcare providers and payors. This position exercises independent judgment in executing, evaluating the process, and recommending improvements to the P2P meeting process to ensure timely, accurate, and efficient case resolution and continuity of care. The P2P Specialist partners with clinical leadership teams, payor representatives, and internal management to facilitate, identify, and resolve scheduling barriers and recommend improvements that align with the Utilization Management Department's goals and objectives.

This position reports directly to the UM Director.

Supervisory Responsibilities:

This position has no direct supervisory responsibilities.

Duties/Responsibilities:

• Oversee and execute the full P2P meeting workflow ensuring operational efficiency, compliance with organizational standards, and identification of opportunities for improvement.
• Exercise discretion and independent judgment in interpreting and applying organizational policies to resolve escalated scheduling conflicts or procedural issues between physicians and insurance medical directors.
• Analyze, develop and recommend approved workflow modifications to the P2P meeting workflow to enhance or maintain productivity, improve efficiency, quality and compliance while minimizing disruption.
• Monitor and track pending or overdue P2P requests to ensure compliance with contractual and operational timelines.
• Maintain detailed and accurate records of all communications, workflow activities, and meeting outcomes.
• Partner with manager to align P2P meeting workflow with the Case Management Department goals and objectives.
• Communicate updates to all relevant stakeholders promptly and professionally.
• Ensure all data, communications and documentation are managed in compliance with HIPAA regulations and organizational confidentiality policies.

Requirements

Required Knowledge/Skills/Abilities:

• Strong understanding of healthcare insurance processes and terminology.
• Demonstrated knowledge of HIPAA compliance and patient privacy requirements.
• Excellent communication, organizational, and time-management skills.
• Proficiency with Microsoft Office Suite and experience with electronic health record (EHR) or scheduling systems.
• Ability to manage multiple priorities in a fast-paced, deadline-driven environment.
• High attention to detail and commitment to accuracy.
• Professional demeanor with the ability to work independently and as part of a team

Education and Experience:

• Associate's degree in healthcare administration, business, or related field preferred (or an equivalent combination of education and experience)
• Minimum of three (3) years' experience in healthcare operations, medical coding or insurance authorization coordination.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift, up to 15 pounds at times.