Strategic Utilization & Authorization Specialist

Duly Health and Care; Downers Grove (IL); On-site; USD 26,000 - 39,000; Full time

Benefits offered by this job

Healthcare benefits

Tuition reimbursement

401(k) match

Volunteer time off

Parental leave

Job summary

Duly Health and Care seeks a qualified Utilization Management Specialist to manage referrals, authorizations, and benefit determinations across capitated and value-based populations. The role emphasizes payer requirements, clinical guidelines, and timely access to care within a collaborative team.

The ideal candidate has 2+ years in utilization management, strong knowledge of CMS guidelines, and proficiency with Epic EHR.

Qualifications

• 2+ years of utilization management or prior authorization experience within a health plan or healthcare system.
• Experience applying CMS and medical necessity criteria in referrals and authorizations.
• Ability to interpret payer requirements and documentation for access to care.

Responsibilities

• Process referrals, authorizations, and benefit determinations per policies and regulations.
• Collaborate with Medical Directors, care teams, and health plans to facilitate timely access to care.
• Maintain accurate documentation in electronic health records and UM systems.
• Identify and escalate complex cases to leadership when needed.

Skills

Utilization management

Prior authorization

Referral management

CMS guidelines

Epic EHR

Education

Associate degree

Healthcare field

Tools

Epic EHR

Job description

Duly Health and Care seeks a qualified Utilization Management Specialist to manage referrals, authorizations, and benefit determinations across capitated and value-based populations. The role emphasizes payer requirements, clinical guidelines, and timely access to care within a collaborative team.

The ideal candidate has 2+ years in utilization management, strong knowledge of CMS guidelines, and proficiency with Epic EHR.