Utilization Management Specialist (Remote)

Cedars-Sinai Medical Center•Los Angeles, CA

1d•Remote

About The Position

The Utilization Management Specialist provides advanced operational and workflow support to Utilization Review (UR) Nurses, helping ensure utilization review activities are timely, accurate, and compliant. The role performs complex non-clinical functions supporting payer communication, authorization coordination, documentation integrity, and regulatory compliance. Working with multiple UR Nurses, the specialist manages an assigned case portfolio and oversees authorization workflows from initial submission through follow-up and final determination. The position requires independent prioritization of cases according to payer deadlines, regulatory requirements, and authorization expiration risk. In collaboration with UR Nurses, Case Management, Revenue Cycle, and external payers, the specialist ensures authorization and documentation activities are complete and accurate and meet established timeframes. The role supports revenue integrity, denial prevention, and compliance with CMS and payer-specific requirements. It operates in a fast-paced, time-sensitive environment using EPIC/CS-Link, AIDIN, payer portals, and related utilization management systems. Remote work is approved in Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, and Texas.

Requirements

High school diploma or GED.
At least 2 years of experience in hospital authorization management, utilization review support, revenue cycle operations, or payer communication processes.

Nice To Haves

Associate's degree or college diploma in business, health, or a related field.
Experience independently managing authorization workflows.
At least 2 years of acute care experience.

Responsibilities

Maintain an assigned portfolio of cases in partnership with UR Nurses to support timely utilization review activities.
Prepare and assemble clinical review packets and supporting documentation for payer submission.
Review records for required documentation elements before submission and escalate gaps to the assigned UR Nurse.
Track submission confirmations and follow up on pending payer determinations in a timely manner.
Manage the authorization lifecycle for assigned cases, including entry, tracking, follow-up, determination documentation, and monitoring payer response timelines.
Monitor payer portals and contact payers as needed to obtain authorization updates and resolve status discrepancies.
Prioritize cases independently based on submission deadlines, authorization expiration risk, and regulatory timeframes.
Escalate urgent authorization issues, delays, or barriers that could result in avoidable denials or authorization lapses.
Coordinate peer-to-peer scheduling logistics and maintain related documentation.
Document and communicate payer determinations, including approvals, partial approvals, and denials, in EPIC/CS-Link according to departmental and regulatory standards.
Identify patterns or systemic authorization workflow issues and communicate trends to UM leadership.
Communicate with internal and external partners to ensure patient and authorization information is current and complete.