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Job Description:

Position Summary

The Utilization Management (UM) Health Services Coordinator provides operational and administrative support for Health Services and Utilization Management activities within the health plan. This role is responsible for coordinating authorization intake and processing, managing UM correspondence and reporting workflows, supporting provider and member inquiries, and ensuring timely, accurate handling of utilization management requests in compliance with Medicare Advantage, CMS, HIPAA, and internal regulatory standards. 

The UM Health Services Coordinator serves as a key liaison between providers, members, clinical staff, claims, and delegated entities to facilitate efficient authorization processing, escalation of clinical reviews, out-of-network coordination, and resolution of operational issues. This position requires strong organizational skills, attention to detail, regulatory awareness, and the ability to manage multiple priorities in a fast-paced managed care environment. 

Essential Duties and Responsibilities 

Utilization Management Operations 

• Coordinate intake, entry, and processing of utilization management requests received via fax, portal, phone, and electronic submissions. 

• Perform preliminary review of authorization requests for completeness, required documentation, eligibility verification, and benefit coverage. 

• Route and escalate requests requiring clinical review to the appropriate nurse or medical director in accordance with UM guidelines and turnaround time requirements. 

• Process expedited authorization requests and assist with required outreach and documentation. 

• Support denial and modification workflows, including preparation, distribution, and documentation of adverse determination notices. 

• Manage additional information requests for incomplete authorization submissions and follow up with providers as needed. 

• Assist with out-of-network (OON) provider searches, wrap network verification, carve-out determinations, and Letters of Agreement (LOAs). 

• Coordinate retroactive review and authorization-related claims resolution activities with claims and clinical teams. 

Correspondence, Reporting, and Documentation 

• Generate, distribute, fax, upload, and maintain authorization-related correspondence, letter logs, and required UM reports. 

• Monitor and manage daily letter reporting processes and ensure timely filing and tracking of documentation. 

• Attach and maintain fax confirmations and supporting records in accordance with departmental procedures and audit standards. 

• Maintain accurate records within health plan systems, databases, and tracking tools. 

• Assist with member and provider loading, eligibility verification, and data maintenance activities. 

Provider and Member Support 

• Respond professionally and accurately to provider, member, and internal staff inquiries regarding authorization status, eligibility, benefits, and UM processes. 

• Answer inbound calls, manage voicemail queues, and respond to departmental email inquiries in a timely manner. 

• Develop and maintain positive working relationships with provider offices, delegated entities, hospitals, and community partners. 

• Provide operational support for pharmacy coordination, medical records requests, and other Health Services functions as assigned. 

Compliance and Regulatory Support 

• Ensure compliance with CMS, Medicare Advantage, HIPAA, NCQA, and internal Aspire Health Plan policies and procedures. 

• Maintain confidentiality of protected health information (PHI) and sensitive member data. 

• Support audit readiness through accurate documentation, tracking, and adherence to turnaround time standards. 

• Participate in process improvement initiatives to enhance operational efficiency, accuracy, and member/provider experience.

Administrative Support 

• Provide administrative and project support to Medical Management leadership and committees as assigned. 

• Assist with departmental projects, workflow updates, and cross-functional operational initiatives. 

• Perform additional duties and responsibilities as assigned. 

Qualifications 

Required Qualifications 

• Associate degree or equivalent combination of education and relevant experience. 

• Minimum of 3–5 years of experience in managed care, health insurance, utilization management, medical office operations, claims, or provider services. 

• Working knowledge of medical terminology, insurance terminology, CPT/HCPCS/ICD coding, and authorization processes. 

• Experience handling high-volume administrative workflows with strong attention to accuracy and detail. 

• Proficiency with Microsoft Office applications, including Excel, Outlook, and Word. 

• Strong written and verbal communication skills. 

• Ability to prioritize multiple assignments and meet regulatory and operational deadlines. 

• Ability to work independently and collaboratively in a fast-paced environment. 

• Strong customer service and problem-solving skills. 

Preferred Qualifications 

• Experience supporting Medicare Advantage and Commercial managed care operations. 

• Knowledge of CMS, HIPAA, NCQA, and utilization management regulatory requirements. 

• Experience working with authorization platforms, electronic medical records, or health plan systems. 

• Bilingual English/Spanish preferred. 

Core Competencies 

• Organizational and Time Management Skills 

• Attention to Detail and Accuracy 

• Regulatory Compliance Awareness 

• Critical Thinking and Problem Solving 

• Professional Communication 

• Customer Service Orientation 

• Adaptability and Flexibility 

• Team Collaboration 

• Confidentiality and Integrity

Aspire Health is an equal opportunity employer. 

Pay rate: 20.00-26.00 

Assigned Work Hours:

8AM-5PM PST

Position Type: