Utilization Management Specialist

At Duly Health and Care you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician‑led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high‑quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve. Benefits: Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance. Access to a mental health benefit at no cost. Employer provided life and disability insurance. $5,250 Tuition Reimbursement per year. Immediate 401(k) match. 40 hours paid volunteer time off. A culture committed to community engagement and social impact. Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non‑physician team members once eligibility requirements are met. Key Responsibilities Utilization Management & Referral Management Process referrals, authorizations, and benefit determinations in accordance with organizational policies, health plan requirements, contractual obligations, and applicable regulatory standards. Perform comprehensive review of referral requests, including eligibility, benefit coverage, medical necessity criteria, network participation, and authorization requirements. Contact health plans and payer representatives to obtain required authorizations, clarify benefits, resolve discrepancies, and facilitate timely access to services. Apply MCG Guidelines, organizational medical management criteria, CMS coverage determinations, and applicable payer‑specific policies when evaluating requests. Ensure medically necessary services are appropriately authorized within the designated provider network and benefit structure. Identify requests that do not clearly meet established criteria and appropriately elevate them to the Medical Director for clinical review and determination. Support denial and adverse determination processes in accordance with health plan requirements, organizational policies, and applicable regulatory standards. Identify potential gaps, barriers, or delays in care and proactively elevate issues that may impact patient access or outcomes. Clinical & Operational Collaboration Partner closely with Medical Directors, Care Management leadership, Clinical Services, providers, physicians, health plans, and other internal stakeholders to facilitate appropriate and timely care. Serve as a subject‑matter resource regarding referral, authorization, utilization management, and payer requirements. Provide clear and professional communication regarding authorization status, clinical documentation requirements, benefit limitations, and next steps. Collaborate with providers and clinical teams to obtain necessary clinical documentation and resolve authorization barriers. Use critical thinking and problem‑solving skills to address complex referral, authorization, and benefit‑related issues. Escalate complex, high‑risk, or unresolved issues to the Utilization Management Supervisor or Manager in a timely manner. Compliance, Quality & Reporting Maintain accurate, complete, and timely documentation within the electronic health record and applicable utilization management systems. Ensure all activities are performed in accordance with HIPAA, CMS requirements, health plan contracts, accreditation standards, and applicable state and federal regulations. Support internal and external audits by maintaining accurate documentation and providing requested records and reporting. Assist with health plan reporting, utilization management metrics, quality initiatives, and operational performance monitoring. Identify opportunities to improve referral and authorization workflows, reduce administrative barriers, and enhance operational efficiency. Maintain confidentiality and exercise appropriate discretion when handling protected health information and sensitive clinical information. Communication & Customer Service Communicate professionally and effectively with patients, providers, physicians, health plans, clinical teams, and organizational leadership through telephone, email, electronic health records, and internal communication platforms. Provide timely resolution or appropriate escalation of questions related to referrals, authorizations, benefits, and network requirements. Demonstrate professionalism, accountability, and sound judgment in interactions with internal and external stakeholders. Adapt effectively to changing payer requirements, regulatory standards, organizational priorities, and evolving healthcare delivery models. Knowledge, Skills & Abilities Strong working knowledge of utilization management, managed care, referral management, and prior authorization processes. Knowledge of health plan benefit structures, provider networks, capitated arrangements, and payer‑specific authorization requirements. Demonstrated ability to interpret and apply MCG Guidelines, CMS coverage policies, and medical management criteria. Strong understanding of medical terminology, healthcare delivery systems, and clinical documentation. Excellent critical‑thinking, analytical, problem‑solving, and decision‑making skills. Ability to evaluate complex information, identify gaps, and determine appropriate next steps. Exceptional organizational and prioritization skills with the ability to manage multiple concurrent requests and deadlines. Strong written and verbal communication skills, with the ability to communicate effectively with both clinical and non‑clinical audiences. Ability to work independently while functioning effectively within a highly collaborative clinical environment. Proficiency with Microsoft Office, electronic health records, and utilization management systems. Experience with Epic or another enterprise‑level EHR preferred. Strong attention to detail and commitment to accuracy, compliance, and timely completion of work. Ability to adapt to changing priorities, payer requirements, workflows, and healthcare regulations. Education Education Associate degree in Healthcare Administration, Nursing, Medical Assisting, Health Information Management, or a related healthcare field preferred. Equivalent combination of education, clinical training, and relevant healthcare experience may be considered. Additional coursework or training in utilization management, medical terminology, coding, healthcare administration, or managed care is preferred. Required Experience Minimum of 2 years of utilization management, prior authorization, referral management, or related managed care experience within a health plan, medical group, IPA, ACO, capitated organization, or healthcare system. Demonstrated experience processing referrals and authorizations in a managed care or capitated environment. Experience applying MCG Guidelines or comparable evidence‑based medical necessity criteria. Experience working directly with health plans and payer representatives. Experience reviewing clinical documentation and determining whether requests meet established criteria. Experience collaborating with Medical Directors, physicians, nurses, providers, or other clinical stakeholders preferred. Medical Assistant, care coordination, health plan operations, or clinical services experience is highly desirable. Preferred Qualifications Candidates with any of the following are strongly preferred: Experience in value‑based care, risk‑based contracting, ACOs, IPAs, or capitated medical groups. Experience working with Medicare Advantage populations and CMS requirements. Experience with complex specialty referrals and multi‑disciplinary healthcare services. Experience supporting utilization management audits, payer audits, or regulatory reviews. Experience with Epic or other enterprise EHR platforms. Experience identifying and implementing process improvements within utilization management or clinical operations. Certification in healthcare administration, utilization management, coding, or a related discipline is a plus. Compensation The compensation for this role includes a base pay range of $39,673.50- $59,510.46 with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Let’s start with what matters. People. Purpose. Care. At Duly Health and Care, we believe healthcare works best when it’s personal, connected, and led by people who truly care. We are a physician‑led medical group built on trusted relationships, teamwork, and a shared commitment to putting patients first in every decision we make. Our team members are caregivers, collaborators, problem‑solvers, and leaders. Together, we show up with compassion, act with purpose, and take ownership of the care we deliver and the experience we create. Whether you’re caring directly for patients or supporting the teams who do, your role matters here, and your voice is valued. We listen with intention, work as one, and challenge ourselves to keep improving, not for recognition, but because our patients, families, and communities count on us. Innovation at Duly isn’t about chasing what’s next for its own sake. It’s about finding better ways to deliver high‑quality, affordable, and accessible care, today and into the future. If you have questions, please connect with your leader or HR Business Partner for support. #J-18808-Ljbffr