Remote Utilization Management Specialist—Payer Support

Cedars-Sinai

Yuma (AZ)

Remoto

USD 70.000 - 90.000

Tempo pieno

6 giorni fa

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Descrizione del lavoro

Cedars-Sinai in the United States is seeking a Utilization Management Specialist to support UR Nurses, ensure timely, accurate, and compliant utilization reviews, and help maintain payer communications and documentation integrity.

You will manage an assigned portfolio of cases, coordinate authorizations across payer portals, and push for timely determinations while adhering to CMS and payer requirements. This role operates in a fast-paced hospital environment with EPIC/CS-Link systems.

Competenze

High school diploma or GED required; associate degree preferred.
Minimum of 2 years of experience in hospital authorization management or payer communication processes.
Experience independently managing authorization workflows preferred.
Minimum of 2 years of acute care experience preferred.

Mansioni

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.