Utilization Management Specialist

The Utilization Management Specialist is a critical member of the Utilization Management team, responsible for the timely, accurate, and clinically appropriate management of referrals, authorizations, and benefit determinations for capitated and value-based health plan populations. 

This role requires a strong understanding of managed care, utilization management, payer requirements, and healthcare benefits, along with the ability to apply clinical guidelines and sound judgment to complex referral and authorization requests. The Utilization Management Specialist partners closely with Medical Directors, Care Management leadership, providers, health plans, and internal clinical teams to facilitate appropriate access to care while ensuring alignment with organizational policies, contractual obligations, regulatory requirements, and evidence-based medical management guidelines. 

The ideal candidate is a highly organized, analytical, and solutions-oriented healthcare professional who can independently manage competing priorities, navigate complex payer requirements, identify potential barriers to care, and effectively communicate with clinical and operational stakeholders. 

Key Responsibilities 

Utilization Management & Referral Management 

• Process referrals, authorizations, and benefit determinations in accordance with organizational policies, health plan requirements, contractual obligations, and applicable regulatory standards. 

• Perform comprehensive review of referral requests, including eligibility, benefit coverage, medical necessity criteria, network participation, and authorization requirements. 

• Contact health plans and payer representatives to obtain required authorizations, clarify benefits, resolve discrepancies, and facilitate timely access to services. 

• Apply MCG Guidelines, organizational medical management criteria, CMS coverage determinations, and applicable payer-specific policies when evaluating requests. 

• Ensure medically necessary services are appropriately authorized within the designated provider network and benefit structure. 

• Identify requests that do not clearly meet established criteria and appropriately escalate them to the Medical Director for clinical review and determination. 

• Support denial and adverse determination processes in accordance with health plan requirements, organizational policies, and applicable regulatory standards. 

• Identify potential gaps, barriers, or delays in care and proactively escalate issues that may impact patient access or outcomes. 

Clinical & Operational Collaboration 

• Partner closely with Medical Directors, Care Management leadership, Clinical Services, providers, physicians, health plans, and other internal stakeholders to facilitate appropriate and timely care. 

• Serve as a subject-matter resource regarding referral, authorization, utilization management, and payer requirements. 

• Provide clear and professional communication regarding authorization status, clinical documentation requirements, benefit limitations, and next steps. 

• Collaborate with providers and clinical teams to obtain necessary clinical documentation and resolve authorization barriers. 

• Use critical thinking and problem-solving skills to address complex referral, authorization, and benefit-related issues. 

• Escalate complex, high-risk, or unresolved issues to the Utilization Management Supervisor or Manager in a timely manner. 

Compliance, Quality & Reporting 

• Maintain accurate, complete, and timely documentation within the electronic health record and applicable utilization management systems. 

• Ensure all activities are performed in accordance with HIPAA, CMS requirements, health plan contracts, accreditation standards, and applicable state and federal regulations. 

• Support internal and external audits by maintaining accurate documentation and providing requested records and reporting. 

• Assist with health plan reporting, utilization management metrics, quality initiatives, and operational performance monitoring. 

• Identify opportunities to improve referral and authorization workflows, reduce administrative barriers, and enhance operational efficiency. 

• Maintain confidentiality and exercise appropriate discretion when handling protected health information and sensitive clinical information. 

Communication & Customer Service 

• Communicate professionally and effectively with patients, providers, physicians, health plans, clinical teams, and organizational leadership through telephone, email, electronic health records, and internal communication platforms. 

• Provide timely resolution or appropriate escalation of questions related to referrals, authorizations, benefits, and network requirements. 

• Demonstrate professionalism, accountability, and sound judgment in interactions with internal and external stakeholders. 

• Adapt effectively to changing payer requirements, regulatory standards, organizational priorities, and evolving healthcare delivery models. 

Knowledge, Skills & Abilities 

• Strong working knowledge of utilization management, managed care, referral management, and prior authorization processes. 

• Knowledge of health plan benefit structures, provider networks, capitated arrangements, and payer-specific authorization requirements. 

• Demonstrated ability to interpret and apply MCG Guidelines, CMS coverage policies, and medical management criteria. 

• Strong understanding of medical terminology, healthcare delivery systems, and clinical documentation. 

• Excellent critical-thinking, analytical, problem-solving, and decision-making skills. 

• Ability to evaluate complex information, identify gaps, and determine appropriate next steps. 

• Exceptional organizational and prioritization skills with the ability to manage multiple concurrent requests and deadlines. 

• Strong written and verbal communication skills, with the ability to communicate effectively with both clinical and non-clinical audiences. 

• Ability to work independently while functioning effectively within a highly collaborative clinical environment. 

• Proficiency with Microsoft Office, electronic health records, and utilization management systems. 

• Experience with Epic or another enterprise-level EHR preferred. 

• Strong attention to detail and commitment to accuracy, compliance, and timely completion of work. 

• Ability to adapt to changing priorities, payer requirements, workflows, and healthcare regulations. 

Education 

• Associate degree in Healthcare Administration, Nursing, Medical Assisting, Health Information Management, or a related healthcare field preferred. 

• Equivalent combination of education, clinical training, and relevant healthcare experience may be considered. 

• Additional coursework or training in utilization management, medical terminology, coding, healthcare administration, or managed care is preferred. 

Required Experience 

• Minimum of 2 years of utilization management, prior authorization, referral management, or related managed care experience within a health plan, medical group, IPA, ACO, capitated organization, or healthcare system. 

• Demonstrated experience processing referrals and authorizations in a managed care or capitated environment. 

• Experience applying MCG Guidelines or comparable evidence-based medical necessity criteria. 

• Experience working directly with health plans and payer representatives. 

• Experience reviewing clinical documentation and determining whether requests meet established criteria. 

• Experience collaborating with Medical Directors, physicians, nurses, providers, or other clinical stakeholders preferred. 

• Medical Assistant, care coordination, health plan operations, or clinical services experience is highly desirable. 

Preferred Qualifications 

Candidates with any of the following are strongly preferred: 

• Experience in value-based care, risk-based contracting, ACOs, IPAs, or capitated medical groups. 

• Experience working with Medicare Advantage populations and CMS requirements. 

• Experience with complex specialty referrals and multi-disciplinary healthcare services. 

• Experience supporting utilization management audits, payer audits, or regulatory reviews. 

• Experience with Epic or other enterprise EHR platforms. 

• Experience identifying and implementing process improvements within utilization management or clinical operations. 

• Certification in healthcare administration, utilization management, coding, or a related discipline is a plus.