Utilization Management Specialist (Remote)

Cedars-Sinai•Los Angeles, CA

1d•$53,186 - $82,430•Remote

About The Position

The Utilization Management Specialist provides advanced operational and workflow support to Utilization Review (UR) Nurses, helping ensure timely, accurate, and compliant execution of the utilization review process. The role performs complex non-clinical functions supporting payer communication, authorization coordination, documentation integrity, and regulatory compliance. The specialist maintains an assigned portfolio of cases in partnership with multiple UR Nurses and oversees authorization workflows from initial submission through follow-up and final determination. The role independently prioritizes cases based on payer deadlines, regulatory requirements, and authorization expiration risk. In collaboration with UR Nurses, Case Management, Revenue Cycle, and external payers, the specialist ensures authorization activities and documentation are complete, accurate, and completed within established timeframes. The position supports revenue integrity, denial prevention, and compliance with CMS and payer-specific requirements. The role operates in a fast-paced, time-sensitive environment using EPIC/CS-Link, AIDIN, payer portals, and related utilization management systems to manage workflows and address administrative barriers that could delay review completion or payer communication. The position is remote and is approved for work from Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, or Texas.

Requirements

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

Nice To Haves

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

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 to confirm required documentation is present 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 authorization workflows for assigned cases, including entry, tracking, follow-up, documentation of determinations, and monitoring payer response timelines.
Monitor payer portals and contact payers as needed to obtain authorization updates and resolve status discrepancies.
Prioritize cases based on submission deadlines, authorization expiration risk, and regulatory timeframes.
Escalate urgent authorization issues, delays, or barriers that may 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.
Ensure required documentation is accurately entered into EPIC/CS-Link according to departmental and regulatory standards.
Communicate effectively with internal and external partners to ensure patient and authorization information is current and complete.