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.

About the Role:

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.