UM Specialist

Point32Health is a leading not‑for‑profit health and well‑being organization dedicated to delivering high‑quality, affordable healthcare. Job Summary Under the direction of the Precertification Team Manager, the UM Specialist is responsible for the daily management of non‑clinical reviews supporting the clinical, business, and program‑related work of the Utilization Management (UM) department. The Specialist functions as a key member of the Utilization Management Team, representing Point32Health’s values to both internal and external customers through written and verbal communication. The UM Specialist coordinates coverage determinations for special handling of designated products or accounts, handles all medical necessity denial letters, and monitors daily processes performed by the coordinator. Responsibilities Writes and edits all denial letters for medical necessity. Participates in a structured training program for new staff. Assists in training existing new employees as new procedures and systems are introduced. Conducts staff audits and assists with managing monitoring tools to ensure quality of work by coordinators. Assists partner departments to resolve claims discrepancies and misdirected activity – exploring root causes and recommendations for resolution. Participates in advanced departmental operational and administrative processes such as requests for departmental information and follow‑up as requested. Participates in projects and special assignments to meet timeliness and department compliance. Represents the department on committees as requested. Other projects and duties as assigned. Qualifications Certification and Licensure Education Required (minimum): Bachelor’s Degree or equivalent relevant work experience. Experience Required (minimum): 3+ years of experience in a managed care/health industry environment. Skill Requirements Excellent verbal and written communication skills. Proficiency and accuracy in performing data entry tasks in multiple applications. Ability to identify urgent situations and follow established protocol. Ability to manage multiple priorities and make sound judgment in a sensitive framework. Initiative‑driven, self‑directed work performance. Strong organizational, problem‑solving, and conflict‑resolution skills with attention to detail. Excellent people skills, involving daily telephone contact with network providers, hospital staff, and internal departments. Working Conditions and Additional Requirements The position is performed under normal office conditions and may include remote work. Typical duties require simultaneous use of a telephone/headset and PC/keyboard, prolonged sitting, and occasional after‑hours work. Salary Range $24.70 – $37.05 per hour. Benefits Medical, dental, and vision coverage Retirement plans Paid time off Employer‑paid life and disability insurance with additional buy‑up coverage options Tuition program Well‑being benefits Full suite of benefits to support career development, individual & family health, and financial health Equal Employment Opportunity We welcome all applicants and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. #J-18808-Ljbffr P32HS Point32Health Services Inc