Utilization Management Specialist

Utilization Management Specialist

Top reasons to work for SMA Healthcare:

• Career growth and advancement potential
• Great benefits such as: Health, Dental, Vision, Life, & Disability Insurance
• Tuition Reimbursement
• Paid Personal Leave and Paid Holidays
• 403b Retirement Plan (matches one to one of employee contribution for the first 3%, then a 50% match on the next 6% of employee contribution)

Essential Job Functions:


1. Exceptional Service: Demonstrate excellent oral and written communication skills.


2. Contact and Scheduling: Scheduling clients for appropriate services, such as wellness visits and addressing gaps in care. Contact clients that have been linked to SMA Healthcare through their insurance plan or benefit plan but have never been to clinic to schedule clients an appointment. Reviewing historical appointments to determine if there are opportunities to engage in further visits that are allowable under health plans for clients engaged in care with SMA Healthcare


3. Communication: Communicate information to program leadership regarding clients that prove difficult to reach or who elect not to set appointments. Building relationships with health plans to work together on outreach to clients that are not engaging in services. Attend all health plan value-based quality reporting calls. Communicate with program leaders on quality metrics and areas for improvement. Inbound and outbound calling and tracking in EMR.

4. Relationship Building: o Build strong relationships with organization leadership, providers, community partners. Review, monitor, and engage clinics in care gap closures for all appropriate payers and clients.


5. Training Plan: Lead and participate in internal and external departmental meetings to maintain and expand business processes, staff education and/or training. Analyze health plan scorecards and/or dashboards to improve patient
compliance and healthcare outcomes. Routinely communicate updates across the organization as appropriate


6. Professionalism: Adhere to professional standards outlined by protocols, policies, and regulations.


7. Training Maintenance: Maintain up-to-date yearly training as required. Periodically attend seminars, payer learning opportunities either by webinar or in person. Perform miscellaneous job-related duties as assigned.

Qualification Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Minimum Education and/or Experience: Possession of a high school diploma or GED. Experience in healthcare quality metrics, value-based contracts, or insurance related functions; or any equivalent combination of education, training and experience which provides the following knowledge, skills, and abilities. Preferred experience: Experience in population health management, knowledge of HEDIS measures, knowledge of health plan care gap reporting, Bilingual.
  Knowledge/Skills/and Abilities:
• Excellent communication and people skills.
• Ability to understand technology-based platforms.
• Problem solving and critical thinking skills.
• Meticulous with strong documentation abilities.
• Ability to follow and understand and stay up-to-date payer claims requirements for commercial, Medicare, Medicaid, and FQHC
• Ability to prepare Excel spreadsheets as needed.
• Mindfulness in preparing reports, updating provider accounts with proper dates.
• Ability to follow verbal and written instructions.
• Ability to read and understand organizational standard operating procedures and policies.
• Ability to establish and maintain effective working relationships with fellow employees and the public

Necessary Special Requirements: Possession of a valid Florida driver's license, acceptable driving record, and proof of personal automobile insurance if required to drive an SMA vehicle and/or use a personal vehicle for SMA business. Complete State of Florida mandatory background screening prior to start of employment. Complete SMA required training during the first six (6) months of employment and updated if required

Physical: Mobility and ability to bend and reach during an 8-12 hour day. Able to lift a minimum of 10 pounds. Visual and auditory acuity sufficient to evaluate, intervene, treat, and record client health care needs. Fine motor skills for legible and accurate charting, daily correspondence, and presentation, either manually or orally. Work endurance ability to work 8-12-hour shifts with a meal break, as possible. Routine 8-12-hour shifts. Hours and days off may vary. Extra hours may be required. Ability to work weekends, evenings, nights, and holidays if position is at a 24-hour facility.

Application: This class specification is intended to identify the class and illustrate the kinds of duties that may be assigned to its incumbents. It should not be interpreted as describing all the duties whose performance may ever be required of such an employee or be used to limit the nature and extent of assignments such individuals may be given.