Utilization Management Specialist

Schedule :

Monday through Friday 8:00 AM - 4:30 PM

Position Summary :

Under general supervision, performs complex administrative duties and statistical, financial, or operations data analysis and reporting in support of management decision making within the functional area. Identifies trends, discrepancies and variances to improve the efficiency and effectiveness of operations. May partner with other departments, divisions, outside agencies, and vendors to address business issues. Exercises various latitudes of independent judgement. May administer or provide high level support for various projects, grants, contracts, implementation of procedures and/or any specialized functions. Assists with orientation, training, or providing task guidance of junior team members.

Job Responsibilities and Performance Standards:

• Processes and answers Sys Aid Tickets regarding authorizations and write-off requests as submitted by staff
• Runs daily, monthly, quarterly reports including but not limited to expiring auths, no auths, registrations lapsed, CMO requests, Void status, Pend status, KPI dashboard (CMO & VA)
• Research and works on reports for correction and trends, communicating actions and trends to programs and supervisors
• Monitors Care Management Auth email for authorization manual uploads and 15-day report from Carelon
• Monitors CMO/Medicare Teams Chat
• Submits Requests for Services onto the HealthShare Referral Manager (HRSM) system for VA clients
• Monitors HealthShare Referral Manager (HRSM) for tasks assigned from VA, uploads required documentation for VA clients
• Coordinates with Centralized Scheduling for new VA referrals and kept appointments
• Submits Outpatient Treatment Requests on GAMMIS portal
• Downloads approved authorizations from GAMMIS portal
• Batches and loads ASO authorization requests and response files
• Completes concurrent ASO authorization requests for Outpatient clinics
• Research and works rejections from ASO, CMO, and VA authorization requests
• Collaborate with Care Management Department staff for clinical review and guidance with authorization requests, rejections, denials, etc.
• Tracks Women's Residential and Transition Registrations and Authorizations.
• Other duties as assigned.

Minimum Qualifications :

• High school diploma or GED AND 2 years of experience required at the lower-level position or position equivalent.
• Must show ability to lead and supervise a team.