Utilization Management Specialist

Coleman Professional Services; Kent (OH); On-site; USD 54,000 - 66,000; Full time

Benefits offered by this job

Competitive salary starting at $60k

Team-oriented culture

Flexible work environment

Professional development opportunities

Paid time off 3 weeks first year

Wellness reimbursement

Job summary

Coleman Health Services is seeking an Utilization Management Specialist. The role supports mental health and substance use treatment programs and may be based at any Coleman location, with preference for Kent, OH.

You will evaluate medical necessity, coordinate prior authorizations, and partner with providers and payers to maximize appropriate reimbursement. The role requires a bachelor’s degree in a relevant field, Ohio licensure, and 5 years in behavioral health, plus EHR and MS Office

Qualifications

• Bachelor's degree in Social Work, Counseling, Psychology or Nursing.
• Current Ohio license.
• 5 years in behavioral health or related field.
• Knowledge of Medicaid Behavioral Health Provider Manual.
• Experience with EHR systems and Microsoft Office.
• Knowledge of Power BI dashboards and SQL is a plus.

Responsibilities

• Develop and implement process for obtaining prior authorizations for client care.
• Develop utilization management strategies and protocols per best practices and regulatory requirements.
• Collaborate with medical staff, case managers and providers to evaluate medical necessity and treatment plan appropriateness.
• Collaborate with payers to ensure timely reimbursement and resolve utilization issues.
• Coordinate with Revenue Cycle Management regarding claims and denials.
• Analyze utilization data to identify opportunities to improve care and reduce non-payment.
• Provide coverage for Compliance Officer during absences.

Skills

Organizational skills

Windows & MS Office

Education

Bachelor's degree in Social Work, Counseling, Psychology or Nursing

Master's degree preferred

Tools

Power BI dashboards

SQL

Electronic Health Record (EHR) system

Job description

Would you like to be part of an award-winning team where you can make a real difference? Coleman Health Services is dedicated to serving our communities and positively impacting the lives of our employees and the people they work to serve. If you are someone who believes in the value of achieving excellence, we want you on our team! As the Utilization Management Specialist, you will evaluate the medical necessity, clinical appropriateness and efficiency of mental health and substance use disorder treatments. Operating as a critical link between treatment providers and insurance payors, this position secures authorization to maximize reimbursement while ensuring clients receive optimal and appropriate care. This position can be based in any Coleman location, with preference of Kent, OH.

What can Coleman offer you as the Utilization Management Specialist?

• Pay starting at $60,000, commensurate with experience
• A positive environment that values teamwork, individuality, innovation, inclusivity, and where we embrace diversity
• Flexibility and empowerment
• You will be encouraged to participate in ongoing learning & developmental opportunities
• Accrue three weeks of paid time off during first year
• Wellness Reimbursement & more!

What are we looking for from you?

• Develop and implement process for obtaining prior authorizations for client care.
• Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
• Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
• Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
• Collaborate with Revenue Cycle Management Director regarding claims payments, denials, and payor-based audits.
• Analyze utilization data and trends to identify opportunities for improving care and reducing non-payment of claims.
• Provide coverage for Compliance Officer during periods of absence

What qualifications will you need to be successful in this role?

• Bachelor's degree in Social Work, Counseling, Psychology or Nursing.
• Current relevant State of Ohio professional licensing
• 5 years experience in behavioral health or related field
• Demonstrated knowledge of current and best practices within behavioral health services
• Demonstrated knowledge of State of Ohio Medicaid Behavioral Health Provider Manual
• Demonstrated proficiency and experience working on an Electronic Health Record System
• Demonstrated ability with Windows and Microsoft Office products
• Exceptional organizational skills and attention to detail

Preference given to the following candidates:

• Master's degree in Social Work, Counseling, Psychology or Nursing.
• 5 years experience in Utilization Management or Quality Assurance
• Current certification in Utilization Management, Compliance or Quality Assurance
• Demonstrated ability with development of Power BI dashboards and/or SQL

We are a nationally recognizednot-for-profit provider of behavioral health and an organization that has demonstrated over 40 years of stability and transparency.

Our Company Culture and Benefits Set Us Apart!

Regardless of your role at Coleman Health Services, your work makes a lasting impact on those we serve. When you join our team, you become part of a collaborative community of dedicated professionals whose primary mission is to improve the lives of our clients. In return, you can also expect opportunities for career advancement and continued professional training.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. E.O.E. Persons with a disability can request an accommodation to complete the application process by emailing [e-mail] with the subject line "Accommodation Request." Coleman Health Services complies with the Federal Drug-Free Workplace Act.