Utilization Management Coordinator
About The Position
Independent Living Systems (ILS), along with its affiliated health plans Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for vulnerable populations. The Utilization Management Coordinator helps ensure authorization requests are processed effectively and contributes to improved member outcomes by facilitating timely access to necessary care. The coordinator reviews prior authorization forms for documentation completeness and determines whether requested services require authorization. The role involves inbound and outbound communication with internal and external customers, including providers.
Requirements
- High school diploma or equivalent; relevant experience may substitute for the educational requirement on a year-for-year basis.
- Two years of experience as a medical office referral/authorization clerk, office assistant, or in another medical office role.
- Strong knowledge of healthcare regulations and medical terminology.
Nice To Haves
- Associate degree in Health Administration or a related healthcare field.
- Certification in Utilization Review, such as Certified Professional in Utilization Review (CPUR), or in Case Management, such as CCM.
- Experience working within managed care organizations or health insurance companies.
- Familiarity with regulatory requirements such as Florida Medicaid/SMMC and CMS guidelines, HIPAA, and current health plan accreditation standards.
Responsibilities
- Demonstrate commitment to the organization’s mission and model ILS Experience Standards of Excellence.
- Continuously review prior authorization requests received orally, through provider portals, by fax, and/or by email to ensure timely processing.
- Screen prior authorization requests for appropriate referral to the Clinical Care Specialist.
- Perform non-medical research, including eligibility verification and reviewing the prior authorization grid to confirm whether services require prior authorization.
- Place outbound calls to providers to request clinical information for review.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
