Utilization Management Specialist

TEKsystems • CA

74d • $21 - $23

About The Position

The Utilization Management Specialist plays a critical role within the Quality Management department, serving as the last line of defense for claims that have been denied. This position is responsible for researching denied claims, gathering necessary information, and facilitating resubmission to Health Plans. The ideal candidate will possess strong verbal and written communication skills and be comfortable interacting with Doctor Offices, Health Plans, and Medical Directors throughout the appeals process.

Requirements

• Minimum 1 year of experience as a Medical Assistant (required).
• Experience in quality improvement, patient care, claims processing, and prior authorization.
• Proficiency with EMR/EHR systems and data entry.
• Excellent verbal and written communication skills.
• Self-motivated, organized, and computer savvy.
• Strong research and letter writing abilities.
• Ability to work independently and collaboratively in a fast-paced environment.

Nice To Haves

• Experience in ambulatory and healthcare settings.
• Familiarity with claims support and appeals processes.
• Demonstrated ability to manage multiple priorities and deadlines.

Responsibilities

• Research and review denied claims to ensure accuracy and completeness prior to resubmission.
• Communicate directly with healthcare providers, Health Plans, and Medical Directors to obtain required documentation and information for appeals.
• Complete and process tasks related to claims support, prior authorizations, and appeals.
• Maintain compliance with internal policies and regulatory requirements.
• Perform data entry and utilize EMR/EHR systems to document findings and actions.
• Support quality improvement initiatives and contribute to departmental goals.

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

What This Job Offers

• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees