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What You Will Do in This Role:

The Utilization Management Specialist provides advanced operational and workflow support to Utilization Review (UR) Nurses to ensure timely, accurate, and compliant execution of the utilization review process. This position performs complex, non-clinical functions that directly support payer communication, authorization coordination, documentation integrity, and regulatory compliance.

The Utilization Management Specialist maintains an assigned portfolio of cases in partnership with multiple UR Nurses and is accountable for oversight of authorization workflows from initial submission, follow-up through to final determination. The role applies independent judgment in prioritizing cases based on payer deadlines, regulatory requirements, and authorization expiration risk.

In collaboration with UR Nurses, Case Management, Revenue Cycle, and external payers, the Utilization Management Specialist ensures documentation and authorization activities are complete, accurate, and executed within established timeframes. This position plays a critical role in supporting 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 UM systems to proactively manage workflows and remove administrative barriers that could delay review completion or payer communication.

• 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 elements are present prior to submission and escalate gaps to the assigned UR Nurse.
• Track submission confirmations and ensure timely follow up on pending payer determinations.
• Manage the authorization lifecycle for assigned cases, including entry, tracking, follow up, documentation of determinations, and monitoring of payer response timelines.
• Monitor payer portals and contact payers directly, as needed, to obtain authorization updates and resolve status discrepancies.
• Independently 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 in accordance with departmental and regulatory standards.
• Identify patterns or systemic authorization workflow issues and communicate trends to UM leadership.
• Document and communicate payer determinations, including approvals, partial approvals, and denials.
• Ensure all required documentation is accurately entered into EPIC/CS-Link in accordance with departmental and regulatory standards.
• Communicate effectively with internal and external partners to ensure patient and authorization information is current and complete.

*Approved Remote States: Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, Texas*

Originally posted on Himalayas