Utilization Management Specialist (Remote)

Cedars-Sinai; Lorida (FL); Remote; USD 70,000 - 90,000; Full time

Job summary

Cedars-Sinai is seeking an Utilization Management Specialist to provide advanced operational support for utilization review processes. You will work with UR Nurses and other teams to ensure timely, accurate, and compliant authorization workflows using EPIC/CS-Link and payer portals.

Responsibilities include preparing documentation, tracking submissions, and communicating determinations within regulatory timeframes to support revenue integrity and prevent denials.

Qualifications

• High school diploma or GED required; associate degree preferred.
• At least 2 years' experience in hospital authorization management or payer communication.
• Experience in independently managing authorization workflows is highly preferred.

Responsibilities

• Maintain a portfolio of cases with UR Nurses to support timely utilization review.
• Prepare and assemble clinical review packets for payer submission.
• Review records to confirm required documentation before submission and escalate gaps.
• Track submission confirmations and follow up on payer determinations.
• Manage the authorization lifecycle from entry to final determination and payer response timelines.
• Communicate with payers to obtain updates and resolve status discrepancies.

Skills

Authorization management

Payer communication

Revenue cycle

Workflow prioritization

Education

High school diploma or GED

Associate degree preferred

Tools

EPIC/CS-Link

Job description

Align yourself with an organization that has a reputation for excellence! Cedars-Sinai was awarded the National Research Corporation’s Consumer Choice Award 19 times for providing the highest-quality medical care in Los Angeles. We also were awarded the Advisory Board Company’s Workplace of the Year. This annual award recognizes hospitals and health systems nationwide that have outstanding levels of employee engagement. We offer an outstanding benefits package that includes health care, paid time off, and a 403(B). Join us! Discover why U.S. News & World Report has named us one of America’s Best Hospitals.

What You Will Do in This Role:

The Utilization Management Specialist provides advanced operational and workflow support to Utilization Review (UR) Nurses to ensure timely, accurate, and compliant execution of the utilization review process. This position performs complex, non-clinical functions that directly support payer communication, authorization coordination, documentation integrity, and regulatory compliance.

The Utilization Management Specialist maintains an assigned portfolio of cases in partnership with multiple UR Nurses and is accountable for oversight of authorization workflows from initial submission, follow-up through to final determination. The role applies independent judgment in prioritizing cases based on payer deadlines, regulatory requirements, and authorization expiration risk.

In collaboration with UR Nurses, Case Management, Revenue Cycle, and external payers, the Utilization Management Specialist ensures documentation and authorization activities are complete, accurate, and executed within established timeframes. This position plays a critical role in supporting revenue integrity, denial prevention, and compliance with CMS and payer specific requirements.

The role operates in a fast‑paced, time-sensitive environment using EPIC/CS-Link, AIDIN, payer portals, and related UM systems to proactively manage workflows and remove administrative barriers that could delay review completion or payer communication.

• 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 escalates 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.
• Document and communicate payer determinations, including approvals, partial approvals, and denials.
• Ensure all required documentation is accurately entered into EPIC/CS-Link in accordance with departmental and regulatory standards.
• Communicate effectively with internal and external partners to ensure patient and authorization information is current and complete.

*Approved Remote States: Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, Texas*

Qualifications

Requirements:

• High school diploma or GED required. Associate's degree or college diploma in business or health or a related field preferred.
• Minimum of 2 years of experience in hospital authorization management, utilization review support, revenue cycle operations, or payer communication processes required.
• Experience independently managing authorization workflows highly preferred.
• Minimum of 2 years of acute care experience preferred.

Why work here?

Beyond outstanding benefits, competitive salaries and health and dental insurance We take pride in hiring the best employees. Our amazing staff reflects the culturally and ethnically diverse community we serve. They are proof of our commitment to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for.