Job Details

Software Guidance & Assistance, Inc., (SGA), is searching for a Utilization Management Specialist for a Contract assignment with one of our premier Healthcare clients in Oakland, CA .

Responsibilities :
The Utilization Management Specialist (UMS) will play a pivotal role in supporting the Utilization Management (UM) team across all three AHS campuses. This multifaceted position will focus on both clinical and administrative functions within the UM department, ensuring seamless operationsand effective management of utilization processes.

• Serve as the primary point of contact for all insurance-related inquiries and interactions. Facilitate clear and accurate communication between the UM department and payers, addressing issues, sending clinical information, and ensuring timely processing and receipt of Inpatient authorizations and/or denials.
• Check all UM fax folders daily to ensure timely receipt and sending of documents.
• Ensure that clinical documentation is faxed to and received by all payers to support inpatient admissions and/or denials.
• Maintain accurate records of all fax communications.
• Check Optum Portal frequently throughout the day to ensure that all determinations are addressed and uploaded to the EPIC charts.
• Obtain initial and concurrent inpatient authorizations from insurance companies for all inpatient admissions.
• Track the status of authorization requests and follow up with insurance companies, as needed.
• Confirm patient's insurance coverage and benefits, as requested.
• Accurately document all communication with insurance companies in EPIC.
• Maintain detailed records of authorization requests, approvals and inpatient denials.
• Update UR team on the status of authorizations, as required.
• Maintains current database of payor contact information.
• Perform accurate data entry into the EHR, ensuring data integrity.
• Manage multiple tasks and responsibilities effectively in a fast-paced, ever-changing environment.
• Prioritize tasks to meet deadlines and support the needs of the department.
• Provide comprehensive administrative assistance to the Utilization Review (UR) team.
• Assist with other duties, as assigned.
• Participate in new staff onboarding, as needed.

Required Skills:

• Required Education: High school diploma or G.E.D.
• Required Experience: Three years in a health Care setting or one year in Utilization Management or Case Management at a Medical Group, Acute Care Environment or health plan experience; Electronic Health Record (EHR) and Utilization Management applications, (e.g. EPIC, or 3M).Must have /very helpful if they have experience in case management for health plan experience.
• Must know Microsoft, Excel and ,Word.
• Must have Epic.
• Excellent organizational and multitasking skills.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook) and other relevant software.
• Effective communication skills, both verbal and written.
• Ability to work autonomously and as a team member in a fast-paced, deadline-driven environment.
• Ability to create and present PowerPoint presentations to large groups.
• Knowledge of payor portals access and use, and insurances (Medicare, Medi-Cal, Commercial).
• Able to receive feedback from leadership.
• Adheres to AHS code of conduct.
• Ability to pay attention to details.

Preferred Skills:

• Preferred Education: Associate degree in related field
• Preferred Experience: Case Management Assistant

SGA is a technology and resource solutions provider driven to stand out. We are a women-owned business. Our mission: to solve big IT problems with a more personal, boutique approach. Each year, we match consultants like you to more than 1,000 engagements. When we say let's work better together, we mean it. You'll join a diverse team built on these core values: customer service, employee development, and quality and integrity in everything we do. Be yourself, love what you do and find your passion at work. Please find us at .

SGA is an Equal Opportunity Employer and does not discriminate on the basis of Race, Color, Sex, Sexual Orientation, Gender Identity, Religion, National Origin, Disability, Veteran Status, Age, Marital Status, Pregnancy, Genetic Information, or Other Legally Protected Status. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, and our services, programs, and activities. Please visit our company EEO page to request an accommodation or assistance regarding our policy.