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Utilization Management Associate Jobs in Hialeah, FL

Elevance Health

Sr Test Analyst PBM

Miami, FL · Hybrid

Validation of Formulary, Utilization Management & Drug List setup using Claims/Query testing ... Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated ...

Elevance Health

Sr Test Analyst PBM

Miami, FL · Hybrid

Validation of Formulary, Utilization Management & Drug List setup using Claims/Query testing ... Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated ...

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All JobsUtilization Management Associate JobsUtilization Management Associate Jobs in Hialeah, FL

Utilization Management Associate information

What does a utilization management associate do?

A Utilization Management Associate is responsible for reviewing healthcare services and determining whether they are medically necessary, appropriate, and efficient. They work with healthcare providers, insurance companies, and patients to ensure that treatments comply with established guidelines and policies. Their role often includes reviewing medical records, processing authorizations, and assisting in the coordination of care to optimize the use of healthcare resources. This position helps control costs while ensuring that patients receive the appropriate level of care.

What skills and qualifications are needed to thrive as a utilization management associate?

A Utilization Management Associate typically needs a background in healthcare administration or a related field, strong analytical skills, and knowledge of medical terminology and insurance guidelines. Familiarity with utilization review software, electronic health records (EHRs), and regulatory compliance systems is important, and certifications like Certified Professional in Healthcare Management (CPHM) can be advantageous. Attention to detail, effective communication, and strong organizational skills help associates excel in evaluating medical necessity and collaborating with care teams. These competencies ensure accurate, efficient review processes that support quality patient care and compliance with payer requirements.

What are the typical daily responsibilities of a utilization management associate?

Utilization Management Associates typically review medical records, verify insurance coverage, and coordinate with healthcare providers to ensure that treatments and services meet established guidelines and payer requirements. They also communicate with physicians and patients to gather necessary information for authorization requests. By ensuring appropriate utilization of healthcare resources, they help support patient care while managing costs and compliance for their organization. Collaboration with clinical staff and insurance representatives is a key part of the role, contributing to effective case management.

What is the difference between Utilization Management Associate vs Utilization Review Coordinator?

AspectUtilization Management AssociateUtilization Review Coordinator
CertificationsTypically requires a healthcare-related certification or licenseOften requires similar certifications, such as CCM or RHIA
Work EnvironmentWorks in insurance companies, healthcare providers, or managed care organizationsWorks in hospitals, insurance companies, or healthcare facilities
Job FocusAssists in reviewing medical necessity and authorization processesCoordinates and conducts utilization reviews and approvals
Common UsageUsed interchangeably in healthcare and insurance settingsOften used in hospital and insurance contexts

The Utilization Management Associate and Utilization Review Coordinator roles share similarities in certifications and work environments, focusing on reviewing medical necessity and authorization. The main difference lies in their specific responsibilities, with associates assisting in the process and coordinators actively conducting reviews and approvals.

What cities near Hialeah, FL are hiring for Utilization Management Associate jobs?

Cities near Hialeah, FL with the most Utilization Management Associate job openings:

Infographic showing various Utilization Management Associate job openings in Hialeah, FL as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 13% Part Time, and 2% Contract. Highlights an 82% Physical, 3% Hybrid, and 15% Remote job distribution.

Utilization Management Coordinator

Miami, FL • On-site

Uloop Inc.
Internet and IT • 1 - 10 employees
Learn more about Uloop Inc.external

Other

Posted 9 days ago

Job description

Utilization Management Coordinator

We are seeking a Utilization Management Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

The Utilization Management Coordinator plays a critical role in ensuring that healthcare services are delivered efficiently and effectively by overseeing the review and authorization of medical treatments and procedures. This position is responsible for coordinating utilization management activities to optimize member care while controlling costs and adhering to regulatory requirements. The role involves collaborating with healthcare providers, insurance companies, and internal teams to evaluate the necessity and appropriateness of medical services. The coordinator will analyze clinical data and documentation to support decision‑making processes and ensure compliance with organizational policies and healthcare standards. Ultimately, this position contributes to improving member outcomes by facilitating timely access to necessary care and preventing unnecessary or redundant services.

Minimum Qualifications
  • High school diploma or equivalent required
  • Minimum of 2 years of experience as a medical assistant, office assistant, or other clinical experience
  • Strong knowledge of healthcare regulations and medical terminology
  • Relevant experience may substitute for the educational requirement on a year‑for‑year basis
Preferred Qualifications
  • Associate degree in Health Administration, or a related healthcare field
  • Certification in Utilization Review (e.g., Certified Professional in Utilization Review - CPUR) or Case Management (e.g., CCM)
  • Experience working within managed care organizations or health insurance companies
  • Advanced knowledge of clinical guidelines and healthcare quality improvement methodologies
  • Familiarity with regulatory requirements such as HIPAA, URAC, and NCQA standards
  • Demonstrated ability to lead or participate in cross‑functional teams focused on utilization management initiatives
Responsibilities
  • Conduct thorough reviews of medical records and treatment plans to determine the medical necessity and appropriateness of requested services
  • Coordinate communication between healthcare providers, insurance representatives, and internal departments to facilitate timely authorization and appeals processes
  • Maintain accurate documentation of utilization management activities and decisions in compliance with regulatory and organizational standards
  • Monitor and analyze utilization data to identify trends, potential issues, and opportunities for process improvement
  • Assist in developing and implementing utilization management policies and procedures to enhance operational efficiency and member care quality
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About ULoop

Sourced by ZipRecruiter

Industry

Internet and it

Company size

1 - 10 Employees

Headquarters location

Nashville, TN, US

Year founded

2007

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