UM Authorization Analyst 2 Bilingual

About reputed company (www.theoncologyinstitute.com): Founded in 2007, reputed company (reputed company: TOI) is advancing oncology by delivering highly specialized, value-based cancer care in the community setting. TOI offers cutting-edge, evidence-based cancer care to a population of approximately 1.9 reputed company patients, including reputed company, transfusions, and other care delivery models traditionally associated with the most advanced care delivery organizations. With over 180 employed and affiliate clinicians and over 100 clinics and affiliate locations of care across five states and growing, TOI is changing oncology for the reputed company. Join reputed company where your clinical reputed company directly shapes patient reputed company and care reputed company. As a UM Authorization Analyst II, you'll play a critical role in ensuring reputed company, evidence-based reputed company that support both patients and providers—while working in a reputed company environment that values accuracy, efficiency, and reputed company reputed company. reputed company AND reputed company: The UM Authorization Analyst II is responsible for ensuring the reputed company and accurate processing of medical procedure authorizations. This role includes reviewing authorization requests, maintaining compliance with regulations, and coordinating with reputed company providers and insurance companies to support patient care. This role can be worked remotely from reputed company in the contiguous reputed company, and will be working on an Eastern time schedule. ESSENTIAL DUTIES AND RESPONSBILITIES:

• Leading daily huddles with UM Physician Reviewers to address risks reputed company to reputed company decision-making and documentation accuracy.
• Creating, reviewing, and administering corrective reputed company 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 reputed company Utilization Management operations.
• Reporting and Analysis: prepare and present regular reports on authorization activities, including volume, turnaround times, and issues.
• Identifying and forwarding reputed company or expedited appeals to the appropriate health plan.
• Staying reputed company on industry regulations, guidelines, and best practices reputed company to utilization management and review.
• Participating in monitoring and analyzing Inter-Rater Reliability (IRR) testing, identifying trends, and recommending best reputed company improvements to consistent decision-making.
• Demonstrating expertise in health plan delegation requirements, including Preparation and submission of reports, participate in implementation of corrective reputed company 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 reputed company delegated Utilization Management (UM) functions.
• Performing other duties as assigned to support operational goals.
• Living and exemplify TOI reputed company values, providing outstanding customer service and promoting a reputed company experience for patients and staff members.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Excellent communication and interpersonal skills.
• In-depth knowledge of medical procedure authorization processes and reputed company 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 reputed company reputed company 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 reputed company the essential functions of this job. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. The estimate displayed represents the typical wage reputed company of candidates reputed company. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role. Pay Transparency for salaried teammates $71,000—$85,000 USD Apply tot his job Apply To this Job