Primary Purpose of Position: The primary responsibility of the Utilization Management Specialist is to demonstrate excellence in all of the activities comprising the UM Program, including but not limited to supporting the following:•Rapid Response Pre-Authorization System (RRS) •UM Program Processes •UM Reporting •URAC & NCQA Accreditation Standards •Regulatory Requirements including HIPAA •UM Policy/Procedure Management •Appeals and Reconsideration processes •Processing of provider pre-authorization requests via Visual Claims or Alignex Systems •Provider Relations ActivitiesDetailed Responsibilities: •Interact and correspond with providers via fax and telephone regarding their treatment plans and questions regarding pre-authorization. •Interact with patients (members) via telephone and US Mail regarding review determinations and UM program requirements •Interact with the clinical staff and peer reviewers within the URUM process and effectively communicate with Practitioner Reviewers to assure accurate and timely decisions are made. •Process practitioner incoming pre-authorization requests using administrative guidelines, policies and procedures. •Support the processing and documentation of reconsiderations and appeals. •Facilitate studies and surveys under the direction of the VP, Clinical Operations, Medical Director and UM Director or Manager. •Assist UM Manager with a variety of tasks that support the UM function including but not limited to assistance in facilitating document preparation, report preparation and meeting management. •Support the efforts of the Quality Management Department and its Programs •Interact with providers and office managers to orient practices new to the URUM requirements. •Assist with managing various policies and procedures as directed by the UM Manager. •Assist in designing/compiling other data supporting various statistics utilized internally to monitor operations. •Assist with ongoing monitoring of our credentialed practitioners by conducting surveillance of OIG (Office of Inspector General) and state licensing update reports. •Participate with all parties involved in AWHN’s Quality & UM programs to continuously improve systems and processes. •Participate in work plan and workgroups to improve QA and UM Programs •Works with QA & UM Program participants to ensure maintenance of URAC and NCQA accreditation; grows knowledge of requirements; participates in committee activities as requiredQualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below represent the knowledge, skills, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities.Education: High School Diploma and Associates Degree or completion of 60 college credits; college graduate with Bachelor’s Degree is preferred Experience: 3 or more years work experience preferably in a health care related field such as managed care or utilization review Language Skills: Ability to read, analyze and interpret documents such as company policies, procedures, and operating instructions; ability to write routine correspondences. Reasoning Ability: Ability to solve practical problems and deal with variables. Ability to interpret various instructions furnished in written, oral, schedule, or electronic form. Ability to organize work to meet deadlines and required turnaround times. Computer Skills: Ability to use computer software required by AWH, including email, word processing and spreadsheets; ability to manipulate data into reports presentable to internal/external parties, e.g., managed care clients, potential clients and vendors. Ability to use common office equipment, e.g., fax, copy machine, printer, scanner etc. Communication Skills: Must exhibit strong interpersonal skills and professionalism. Strong verbal, telephonic and written communication skills are required. Ability to work under pressure; must have strong listening skills. Ability to build relationships with internal/external customers. Ability to work with practitioners and office managers in an educational and in a problem solving role. Ability to work with offsite physician and clinical leadership (medical directors, clinical reviewers and committee members). Team Skills: Ability to support the team goals, initiatives, members in a fast paced regulatory environment.Physical Demands: The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with other employees and external personnel in person, by telephone, and electronically. Specific vision abilities required by this job include close vision.Work Environment: The work environment characteristics described here represent that an employee encounters while performing the essential functions of this job. While performing the duties of this job, the employee regularly works in an office environment with moderate noise levelsWe are proud to be an EEO/AA employer M/F/D/V.