Utilization Management Specialist

At Duly Health and Care you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do.

With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits:

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

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.

If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.

The compensation for this role includes a base pay range of $39,673.50- $59,510.46 with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.