System Utilization Management SUM Specialist

Alameda Health System; Oakland (CA); On-site; USD 47,000 - 79,000; Full time

Job summary

Alameda Health System in Oakland, California, seeks a System Utilization Management Specialist to support the UM team across all campuses. You will handle payer communications, authorizations, and data entry in EPIC, ensuring timely processing of inpatient cases.

The role emphasizes clinical and administrative duties within Utilization Management, with potential system-wide coverage and onboarding involvement.

Qualifications

• Associate degree or 2–3 years of health education/related experience in inpatient, skilled nursing, home health, health plan or related setting.
• Minimum three (3) years in a health care setting with interdisciplinary team/patients/families.
• Hospital or health plan experience preferred.

Responsibilities

• Serve as payer liaison and primary contact for insurance inquiries, communicating with payers and documenting in EPIC.
• Manage inpatient authorization processes: obtain initial and concurrent authorizations and track status.
• Maintain accurate records of fax communications and ensure clinical documents reach payers.

Skills

Payer liaison

Data entry

Multitasking

Communication

Interdisciplinary teamwork

Education

Associate degree or equivalent experience

3 years health care experience

Tools

EPIC

Optum Portal

Job description

System Utilization Management SUM Specialist

Alameda Health System Oakland, California, United States

About this position

SUMMARY: The System Utilization Management Specialist (UMS) will play a pivotal role in supporting the Utilization Management (UM) team across all three AHS campuses. The UMS will report directly to the UM Manager. This multifaceted position will focus on both clinical and administrative functions within the UM department, ensuring seamless operations and effective management of utilization processes.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

• Payer Liaison: Serve as the primary point of contact for all insurance-related inquiries and interactions. Facilitate clear and accurate communication between the UM department and payers, addressing issues, sending clinical information, and ensuring timely processing and receipt of Inpatient authorizations and/or denials.
• Fax Management:
  • Check all UM fax folders daily to ensure timely receipt and sending of documents.
  • Ensure that clinical documentation is faxed to and received by all payers to support inpatient admissions and/or denials.
• Maintain accurate records of all fax communications.
• Optum Portal Management: Check Optum Portal frequently throughout the day to ensure that all determinations are addressed and uploaded to the EPIC charts.
• Authorization Management:
  • Obtain initial and concurrent inpatient authorizations from insurance companies for all inpatient admissions.
  • Track the status of authorization requests and follow up with insurance companies, as needed.
    • Confirm patient's insurance coverage and benefits, as requested.
    • Accurately document all communication with insurance companies in EPIC.
    • Maintain detailed records of authorization requests, approvals and inpatient denials.
    • Update UR team on the status of authorizations, as required.
    • Maintains current database of payor contact information.
• Data Entry and Reporting: Perform accurate data entry into the EHR, ensuring data integrity.
• Multitasking and Prioritization:
  • Manage multiple tasks and responsibilities effectively in a fast-paced, ever-changing environment.
  • Prioritize tasks to meet deadlines and support the needs of the department.
• Administrative Support:
  • Provide comprehensive administrative assistance to the Utilization Review (UR) team.
  • Assist with other duties, as assigned.
  • Participate in new staff onboarding, as needed.
  • May have to float throughout the system to different locations.

MINIMUM QUALIFICATIONS:

• Required Education: Associate degree is required, OR equivalent years of experience, as typically found in 2-3 years of health education in an inpatient, skilled nursing, home health, health plan or related setting.
• Preferred Education: Equivalent experience will be accepted in lieu of the required degree or diploma.
• Required Experience: Minimum three (3) years in health care setting working directly with interdisciplinary team/patients/families in a clinical team setting. Hospital and/or Health Plan experience.
• Preferred Experience: Experience coordinating benefits, obtaining authorizations, Hospital experience.

The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate's experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.

$34.45/hr - $57.43/hr

Salary Information

$34.45 - $57.43Hourly Wage