Job Description
The Advanced Utilization Management Operations Specialist provides advanced operational expertise to support complex case resolution, utilization management inventory oversight, escalations, and workflow support. This position is responsible for investigating authorization cases and operational issues that cannot be resolved through standard workflows, determining where breakdowns occurred, and driving issues through resolution.
The Advanced Utilization Management Operations Specialist partners with clinical, operational, quality, compliance, medical policy, coding, configuration, and client facing teams to ensure case resolution and recommendations are accurate, compliant, operationally sound, and completed timely. Success in this role requires strong attention to detail, critical thinking, organization, sound operational judgment, and the ability to manage multiple high priority issues while maintaining follow through.
JOB RESPONSIBILITIES
Complex Case Escalation and Resolution
- Serve as an escalation resource for complex, incorrectly processed, or difficult to resolve authorization cases.
- Investigate provider, health plan, and internal escalations to determine what occurred, what should have occurred, and the appropriate corrective action.
- Reconstruct case activity across systems, documentation, benefit information, authorization history, and workflow activity to identify root cause.
- Resolve cases that cannot be addressed through standard frontline workflows and coordinate resolution across teams when necessary.
- Ensure identified issues are followed through to completion rather than transferred between teams without resolution.
- Escalate potential member impact, compliance concerns, or systemic issues to appropriate leadership.
UM Inventory Management
- Support daily management and oversight of utilization management inventory.
- Identify cases that are missing, misrouted, stalled, incorrectly assigned, or located outside the expected workflow.
- Investigate discrepancies between operational inventory, system activity, and reporting.
- Identify inventory at risk of exceeding required turnaround times and assist with prioritization and resolution.
- Support management of aged, complex, or otherwise difficult to resolve inventory.
- Proactively identify workflow or inventory patterns that could create future operational risk.
Root Cause Analysis and Problem Solving
- Investigate operational errors and workflow breakdowns to determine the underlying cause.
- Distinguish between individual performance issues, training or knowledge gaps, unclear processes, system configuration issues, benefit interpretation issues, and broader operational defects.
- Identify recurring patterns across escalations and individual case findings.
- Recommend practical corrective actions based on identified root causes.
- Partner with UM leadership, Quality, Compliance, Medical Policy, Coding, Configuration, and other teams as appropriate to resolve identified issues.
- Support remediation and follow through when issues have potential client, member, provider, or regulatory impact.
UM Operational Subject Matter Expertise
- Serve as a resource to frontline staff and leadership for complex DMEPOS utilization management workflows.
- Apply knowledge of benefit determination, eligibility, authorization requirements, clinical review pathways, and operational requirements when resolving cases.
- Understand and reinforce the appropriate order of operations and critical decision points required for accurate authorization processing.
- Help staff determine how to approach unfamiliar scenarios rather than relying solely on scenario specific instructions.
- Support development and refinement of operational workflows, reference materials, escalation pathways, and decision support tools.
Key Competencies
- Critical thinking, problem solving, complex case investigation, and root cause identification.
- DMEPOS and utilization management knowledge, inventory management, and workflow management.
- Attention to detail, operational decision making, accountability, and follow through.
- Cross functional collaboration and ability to work effectively in a fast paced and evolving environment.
Measures of Success
- Timely resolution of complex UM escalations.
- Reduction in unresolved, stalled, or misrouted inventory.
- Reduction in repeat operational errors and rework.
- Improved identification and resolution of root causes.
- Improved adherence to established UM workflows and critical decision points.
- Timely identification and escalation of potential member, client, or compliance risk.
- Improved operational stability and efficiency across the utilization management function
Pay: $24.00/hour
EDUCATION:
- High school diploma or equivalent required;
- Associate’s or Bachelor’s degree in Healthcare Administration, Nursing, Business Administration,
- or related field preferred.
Experience:
- Minimum of 5 years of experience in utilization management, prior authorization, healthcare operations, or a related healthcare function preferred.
- Strong knowledge of utilization management and prior authorization workflows required.
- DMEPOS experience strongly preferred.
- Experience researching and resolving complex authorization, benefit, or operational issues required.
- Experience with Medicare, Medicaid, and Commercial health plan requirements preferred.
- Experience with delegated utilization management preferred.
- Strong understanding of the relationship between benefit coverage, authorization requirements, clinical review, and operational processing.
- Demonstrated ability to navigate multiple systems and sources of information to reconstruct case activity and determine root cause.
- Strong analytical, investigative, critical thinking, and problem solving skills.
- Ability to recognize patterns and distinguish isolated errors from broader process or system issues.
- Strong organizational skills and ability to manage multiple high priority issues simultaneously.
- Excellent written and verbal communication skills.
- Ability to collaborate effectively across clinical, operational, technical, quality, compliance, and client facing teams.
- Strong Microsoft Excel and Microsoft Office skills.
Benefits Offered
- Competitive compensation and annual bonus program
- 401(k) retirement program with company match
- Company-paid life insurance
- Company-paid short term disability coverage (location restrictions may apply)
- Medical, Vision, and Dental benefits
- Paid Time Off (PTO)
- Paid Parental Leave
- Sick Time
- Paid company holidays and floating holidays
- Quarterly company-sponsored events
- Health and wellness programs
- Career development opportunities
Remote Opportunities
We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.
Our Story
Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.
With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.
Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.
Originally posted on Himalayas
