Healthcare Utilization Management Jobs

1 to 3 years Managed Care, Insurance, Call Center Experience

Minimum 1 year general office and/or customer service experience required.

Work experience in healthcare setting required.

Knowledge of medical terminology required

Your career starts now. We’re looking for the next generation of health care leaders.

3 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.

Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.

Knowledge of electronic medical records (EMR) and medical terminology.

Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.

Bilingual in English and Spanish.

Knowledge of educational assessments and learning strategies.

Completes member health screenings to identify needed services and completes member referrals in accordance with to benefit plan.

Monitors member admissions, enters discharge dates and disposition, and refers to needed services in accordance with to benefit plan.

Minimum of one year experience in a healthcare-related field.

Experience with medical terminology and concepts used in the healthcare delivery system, provider office, or the insurance industry is required.

Advanced technical skills in the use of hardware and software with a high degree of accuracy.

Understanding and/or experience with Utilization Management. (R)

Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws. Responsibilities include:

Minimum two years of experience in a supervisory capacity in a managed care setting. (R)

Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R)

Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.

Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)

10+ years of digital product management experience creating strategic product roadmaps and working with cross-functional teams

Proven experience working in an Agile environment, SAFe certification a plus*

Integrate usability studies, research, and market analysis into product requirements to enhance user satisfaction

Lead and mentor product owners and business analysts as the Product Manager on a Release Train within our SAFe delivery framework

Experience driving product vision, design discussions, and developing new products & technologies

Knowledge of full product development lifecycle

4 year(s): Supervisory or management experience preferably in a heath care setting.

Follows document management practices consistent with organizational policies and procedures, and appropriate for the type of service request

Bachelor’s degree in Business or Accounting, or related field from an accredited college, or equivalent experience/combined education

Participates in ongoing educational and/or training activities as required

Perform other duties and responsibilities as assigned

Working knowledge of medical terminology

2 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.

Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.

Knowledge of electronic medical records (EMR) and medical terminology.

Ability to take direction, offer useful insight into work processes & brainstorm when challenges arise. Strong ability to work collaboratively.

Retrieves medical records and scans documents to assist with the facilitation of the UM department.

Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.

Medical terminology training, time management skills, organizational skills

Preferred Skills, Capabilities and Experiences:

May act as liaison between Medical Management and internal departments

This position can be filled at Utilization Management Representative II.

Manage incoming calls or post services claims work

Determine contract and benefit eligibility

Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.

Five or more years of clinical practice experience.

Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions.

Participate in inter-rater reliability activities.

Participate in analysis of utilization data and suggest improvement opportunities.

Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility.

• Monitor systems reports and dashboards for case management impact; proactively adjust as necessary.

• Expert with best-in-class call center management principles, metrics and practices.

• Excellent organizational skills and ability to manage multiple projects in a fast-paced environment.

• Other duties and responsibilities as assigned.

• Advanced problem-solving and analytical skills to address complex and multi-faceted business problems; STRONG quantitative orientation.

• Outstanding verbal and written communication skills.

Knowledge of basic medical terminology and concepts used in managed care.

2 years’ experience in health care/managed care setting or previous work experience within division.

Title: Healthcare Utilization Management Coordinator

This is 100% Remote Opportunity

3 years experience in health care claims/service areas or office support.

Excellent communication, organizational and customer service skills.