Clinical Utilization Management Specialist

1 month ago


Burbank, California, United States Vivo HealthStaff Full time
Job Overview

Vivo HealthStaff is seeking a highly skilled Clinical Utilization Management Specialist to join our team. This role is crucial in ensuring a streamlined and compliant denial process, aligning with regulatory, accreditation, and health plan standards.

Key Responsibilities
  • Oversee denial unit staff, managing daily tasks, performance reviews, and disciplinary actions.
  • Foster effective communication and collaboration with physician reviewers, medical directors, and other departments.
  • Ensure timely responses to requests and maintain high standards of compliance and privacy.
  • Assist in preparing reports, including departmental work-plans and audits.
  • Monitor and enhance the quality of the denial process internally.
  • Design and deliver training sessions for denial unit staff.
  • Stay updated with state and federal regulations related to the department and implement necessary changes.
  • Lead the department towards achieving set objectives and provide guidance to team members.
  • Implement procedures to ensure alignment with company policies and influence process improvements.
Qualifications
  • Graduate from an accredited Registered Nursing Program; RN preferred.
  • Minimum of five years in prior-authorization, appeals & grievance, or health plan compliance.
  • Proven experience in project development, staff supervision, and performance monitoring.
  • Strong communication skills, both verbal and written.
  • Ability to manage multiple projects in a high-stress environment and adapt to changing priorities.
  • Proficiency in MS Office and a computerized environment.
  • Valid CA driver's license and car insurance.
Policies
  • Uphold honesty and integrity.
  • Adhere to privacy, compliance policies, and the corporate code of conduct.
  • Lead and participate in team meetings and promote organizational goals.
  • Provide top-tier customer service and be adaptable to flexible work hours.
Benefits
  • Comprehensive healthcare coverage.
  • Competitive 401k plan.

Vivo HealthStaff is a healthcare staffing and recruitment firm based in the San Francisco Bay Area, providing permanent and temporary opportunities to organizations across the United States.



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