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Prior Authorization Utilization Review Jobs in Colorado

Medix

Authorization Specialist

Denver, CO · On-site

$23 - $26.50/hr

Submit medical prior authorization requests via payer portals, phone, or fax based on payer ... and utilization review processes is preferred. Skills * Medical Documentation & Record Review:

UHS

DIR - UTILIZATION REVIEW / MGMT

Colorado Springs, CO · On-site

$85K - $120K/yr

Reviews all cases for days that were not authorized to determine appeal options. Conducts routine ... Provides Utilization Management consultations to UM department and other hospital departments as ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are popular job titles related to Prior Authorization Utilization Review jobs in Colorado?

For Prior Authorization Utilization Review jobs in Colorado, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Colorado look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Colorado are:

What cities in Colorado are hiring for Prior Authorization Utilization Review jobs?

Cities in Colorado with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you

Authorization Specialist

Medix

Denver, CO • On-site

$23 - $26.50/hr

Full-time

Medical, Dental, Vision, Retirement

Posted 6 days ago

Job description

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking an Authorization Specialist to play a critical role in reviewing clinical documentation and medical records. The primary focus will be on Durable Medical Equipment (DME) authorizations. This role operates in a non-clinical capacity to ensure documentation completeness, accuracy, and alignment with payer requirements before the authorization submission. This position requires meticulous attention to detail, strong non-clinical record interpretation skills, and active communication with internal leadership and team members to ensure compliance and timely approval determinations.
Key Responsibilities
  • Conduct detailed reviews of medical records, clinical notes, order documents, and claims history to determine if items meet established insurance medical necessity criteria.
  • Compare submitted documentation against specific payer guidelines, internal quality standards, and standard operating procedures.
  • Identify documentation gaps, inconsistencies, or missing clinical information, and communicate findings clearly to designated internal team members.
  • Log review outcomes, case notes, and documentation status updates accurately into electronic case management tools and tracking systems.
  • Prepare structured written summaries of review findings, citing specific missing elements or supporting clinical evidence.
  • Submit medical prior authorization requests via payer portals, phone, or fax based on payer-specific guidelines.
  • Track and follow up on submitted prior authorizations until a final approval or determination is rendered by the health plan.
  • Maintain strict adherence to HIPAA guidelines, patient privacy standards, and company confidentiality policies.
  • Follow defined escalation paths when complex clinical documentation requires supervisory input or advanced clarification.
  • Meet or exceed defined daily productivity, accuracy, and quality metrics.
  • Participate in calibration sessions, workflow training, and regular process updates regarding evolving payer rules and internal review protocols.
  • Perform additional administrative support and order documentation tasks as assigned.

Qualifications
  • High school diploma or GED equivalent required; Associate degree or healthcare-related coursework preferred.
  • Minimum of three (3) years of experience reviewing and interpreting clinical records, medical documentation, insurance claims, or healthcare orders.
  • Solid understanding of basic medical terminology and the ability to interpret patient charts, diagnoses, treatment plans, and clinical notes.
  • Strong analytical skills and attention to detail to uncover documentation gaps and inconsistencies.
  • Excellent written and verbal communication skills for summarizing findings and documenting case details.
  • Proficiency in Microsoft Office applications (Excel, Word, Outlook) and the ability to quickly adapt to proprietary web portals and electronic case management systems.
  • Proven ability to manage multi-task workflows effectively in a fast-paced environment while meeting productivity goals.
  • Direct experience reviewing documentation for Durable Medical Equipment (DME), home health, specialty pharmacy, or prior authorizations is preferred.
  • Previous experience submitting and tracking prior authorizations through insurance payer portals or electronic medical record (EMR) systems is preferred.
  • Familiarity with commercial and government payer coverage guidelines, audit practices, and utilization review processes is preferred.

Skills
  • Medical Documentation & Record Review: Analyzes and interprets clinical notes, medical records, and order documentation in a non-clinical capacity.
  • DME & Payer Medical Necessity Guidelines: Consistently applies established payer criteria, medical necessity guidelines, and internal standard operating procedures to verify coverage eligibility.
  • Quality Assurance & Verification: Identifies missing clinical notes, incomplete orders, or discrepancies in documentation with a high degree of precision.
  • Written & Verbal Communication: Prepares clear, concise summaries of documentation findings and maintains effective communication regarding authorization statuses and missing items.
  • Authorization Management & Compliance: Accurately submits prior authorization requests to insurance carriers and follows up systematically until a final coverage determination is rendered.
  • Time Management & Productivity: Manages competing case priorities efficiently while meeting operational productivity targets, turnaround times, and quality standards.

Benefits
  • Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
  • Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
  • 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
  • Short Term Disability Insurance.
  • Term Life Insurance Plan.

* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Any required state or Joint Commission training is compensated at the state or local minimum wage rate.
* As a job position within our Revenue Cycle division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, handling financial and other payment data, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
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About Medix Staffing Solutions

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Since 2001, we’ve been dedicated to helping you achieve your goals. Medix was created to become a leading provider of workforce solutions for clients and candidates across the healthcare and life sciences industries. Today, we are that leader. Headquartered in Chicago, we have 23 offices across the United States, and staff talent around the world. Medix is committed to fulfilling our core purpose as an organization: to positively impact the lives of our talent, clients, and teammates through employment, philanthropy, and opportunity. The combination of purpose and values has nurtured our thriving culture that encourages our internal team to excel at work and in everyday life.

Industry

Recruiting and staffing services

Company size

1,001 - 5,000 Employees

Headquarters location

Chicago, IL, US

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