Care Access & Utilization Specialist

Midwest Physicians Administrative Services, LLC dba Duly Health and Care; Highland Oaks (GA); On-site; USD 26,000 - 39,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

Mental health benefit

Life and disability insurance

Tuition reimbursement up to $5,250 per

401(k) match

Paid volunteer time off (40 hours)

Parental leave up to 12 weeks

Adoption and surrogacy financial help

Job summary

Duly Health and Care is seeking a detail-oriented Utilization Management Specialist to manage referrals, authorizations, and benefit determinations for capitated and value-based populations. You will collaborate with Medical Directors, care teams, and health plans to ensure compliant, timely access to care.

The role requires strong knowledge of UM processes, payer requirements, and clinical guidelines, with excellent organizational and communication skills to navigate complex cases.

Qualifications

• Minimum 2 years in utilization management or prior authorization.
• Experience with CMS guidelines and medical necessity criteria.
• Ability to work with health plans, providers, and internal teams.

Responsibilities

• Process referrals and authorizations per policy.
• Review eligibility, benefits, and medical necessity.
• Coordinate with health plans to obtain required approvals.
• Escalate complex cases to Medical Director for clinical review.
• Maintain documentation within EHR and UM systems.

Skills

Utilization management

Prior Authorization

Referral management

Managed care

Healthcare terminology

Critical thinking

Communication

Epic EHR

Education

Associate degree in Healthcare Administration

Healthcare-related field preferred

Tools

Epic EHR

Job description

Duly Health and Care is seeking a detail-oriented Utilization Management Specialist to manage referrals, authorizations, and benefit determinations for capitated and value-based populations. You will collaborate with Medical Directors, care teams, and health plans to ensure compliant, timely access to care.

The role requires strong knowledge of UM processes, payer requirements, and clinical guidelines, with excellent organizational and communication skills to navigate complex cases.