Utilization Manager Jobs in New Port Richey, FL (NOW HIRING)

Join a team where your clinical insight directly shapes patient outcomes and care quality. As a UM Authorization Analyst II, you'll play a critical role in ensuring timely, evidence-based decisions that support both patients and providers—while working in a collaborative environment that values accuracy, efficiency, and professional growth.

JOB PURPOSE AND SUMMARY:

The UM Authorization Analyst II is responsible for ensuring the timely and accurate processing of medical procedure authorizations. This role includes reviewing authorization requests, maintaining compliance with regulations, and coordinating with healthcare providers and insurance companies to support patient care.

This role can be worked remotely from anywhere in the contiguous United States, and will be working on an Eastern time schedule.

ESSENTIAL DUTIES AND RESPONSBILITIES:

• Leading daily huddles with UM Physician Reviewers to address risks related to timely decision-making and documentation accuracy.
• Creating, reviewing, and administering corrective action forms with support and guidance from the Director, Utilization Management Compliance.
• Managing denial and/or appeal escalations and communicating delays to the Director, Utilization Management Compliance.
• Working closely with the Director, Utilization Management Compliance to identify deficiencies and areas for improvement.
• Partnering with delegated entities to ensure the accuracy and compliance of provider credentialing processes, conducting thorough sanction and exclusion checks, and promoting the effective utilization of QuickCap workflows within Utilization Management operations.
• Reporting and Analysis: prepare and present regular reports on authorization activities, including volume, turnaround times, and issues.
• Identifying and forwarding standard or expedited appeals to the appropriate health plan.
• Staying current on industry regulations, guidelines, and best practices related to utilization management and review.
• Participating in monitoring and analyzing Inter-Rater Reliability (IRR) testing, identifying trends, and recommending best practice improvements to consistent decision-making.
• Demonstrating expertise in health plan delegation requirements, including Preparation and submission of reports, participate in implementation of corrective action plans (CAPs), updates to policies and procedures, and monitoring and applying regulatory changes to maintain contractual compliance.
• Ensuring adherence to key performance indicators (KPIs) and service level agreements (SLAs) for all delegated Utilization Management (UM) functions.
• Performing other duties as assigned to support operational goals.
• Living and exemplify TOI core values, providing outstanding customer service and promoting a positive experience for patients and staff members.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Excellent communication and interpersonal skills.
• In-depth knowledge of medical procedure authorization processes and healthcare insurance requirements.
• Ability to analyze data and implement process improvements.
• Proficiency with medical billing software and electronic health records (EHR) systems.
• Strong organizational skills and attention to detail.
• Strong understanding of evidence-based guidelines (MCG, National Coverage Determinations, Local Coverage Determinations).
• Understanding of prior authorization regulatory requirements and turnaround time expectations (CMS, AHCA, NCQA, URAC).

REQUIRED EXPERIENCE, EDUCATION AND/OR TRAINING:

• Associate's degree in health information management, or a healthcare related field. Bachelor's preferred.
• 4-6 years of experience in utilization management.
• Bilingual in English and Spanish required.

PHYSICAL WORKING REQUIREMENTS:

The position involves prolonged periods of sitting at a desk, extensive computer use, and phone interaction. Additionally, the role may require occasional lifting of up to 20 pounds for office supplies or equipment.

The physical demands described above are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.