Utilization Management Coordinator

Socket.dev; Miami (FL); On-site; USD 42,000 - 64,000; Full time

Job summary

Independent Living Systems (ILS) is seeking a Utilization Management Coordinator to join our team. This role reviews prior authorization requests, determines if authorization is required, and communicates with providers and internal teams to ensure timely access to care.

You will help improve member outcomes by supporting the Clinical Care Specialist and coordinating non-medical information gathering, eligibility checks, and documentation workflow.

Qualifications

• High school diploma or equivalent required.
• 2 years of medical office experience or related role.
• Strong knowledge of healthcare regulations and medical terminology.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Responsibilities

• Review prior authorization requests for documentation completeness and determine if an authorization is required.
• Communicate with providers and internal/external customers to facilitate timely processing.
• Screen requests and route to Clinical Care Specialist as appropriate.
• Support non-medical research, eligibility verification, and information gathering for reviews.

Skills

Healthcare regulations

Medical terminology

Communication skills

Prior authorization processing

Provider coordination

Education

Associate degree in Health Administration

CPUR or CCM certification

Job description

We are seeking a Utilization Management Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Utilization Management Coordinator plays an essential role in ensuring that the authorization requests are processed effectively. The Utilization Management Coordinator reviews the prior authorization form received for documentation completeness and determines if the requested service requires an authorization. This role includes inbound and outbound communication with both internal and external customers. Ultimately, the Utilization Management Coordinator contributes to improving member outcomes by facilitating timely access to necessary care.

Minimum Qualifications:

• High school diploma or equivalent required
• 2 years of experience as a medical office referral/authorization clerk, office assistant or other medical office experience.
• Strong knowledge of healthcare regulations, and medical terminology.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Preferred Qualifications:

• Associate degree in Health Administration, or a related healthcare field
• Certification in Utilization Review (e.g., Certified Professional in Utilization Review - CPUR) or Case Management (e.g., CCM).
• Experience working within managed care organizations or health insurance companies.
• Familiarity with regulatory requirements such as Florida Medicaid/SMMC and CMS guidelines, HIPAA and current health plan accreditation standards,.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Continuously reviews prior authorization requests received via oral, provider portal, fax and/or email to ensure timely processing.
• Screens prior authorization requests for appropriate referral to the Clinical Care Specialist.
• Performs non-medical research including eligibility verification, reviewing the prior authorization grid to confirm if services do or do not require prior authorization.
• Places outbound calls to providers to request clinical information for review.
• Perform other duties as assigned.