Utilization Management Specialist

At Duly Health and Care you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician‑led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high‑quality, coordinated care.

Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits:

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non‑physician team members once eligibility requirements are met.

• Utilization Management & Referral Management Process referrals, authorizations, and benefit determinations in accordance with organizational policies, health plan requirements, contractual obligations, and applicable regulatory standards.
• Perform comprehensive review of referral requests, including eligibility, benefit coverage, medical necessity criteria, network participation, and authorization requirements.
• Contact health plans and payer representatives to obtain required authorizations, clarify benefits, resolve discrepancies, and facilitate timely access to services.
• Apply MCG Guidelines, organizational medical management criteria, CMS coverage determinations, and applicable payer‑specific policies when evaluating requests.
• Ensure medically necessary services are appropriately authorized within the designated provider network and benefit structure.
• Identify requests that do not clearly meet established criteria and appropriately elevate them to the Medical Director for clinical review and determination.
• Support denial and adverse determination processes in accordance with health plan requirements, organizational policies, and applicable regulatory standards.
• Identify potential gaps, barriers, or delays in care and proactively elevate issues that may impact patient access or outcomes.

• Partner closely with Medical Directors, Care Management leadership, Clinical Services, providers, physicians, health plans, and other internal stakeholders to facilitate appropriate and timely care.
• Serve as a subject‑matter resource regarding referral, authorization, utilization management, and payer requirements.
• Provide clear and professional communication regarding authorization status, clinical documentation requirements, benefit limitations, and next steps.
• Collaborate with providers and clinical teams to obtain necessary clinical documentation and resolve authorization barriers.
• Use critical thinking and problem‑solving skills to address complex referral, authorization, and benefit‑related issues.
• Escalate complex, high‑risk, or unresolved issues to the Utilization Management Supervisor or Manager in a timely manner.

• Maintain accurate, complete, and timely documentation within the electronic health record and applicable utilization management systems.
• Ensure all activities are performed in accordance with HIPAA, CMS requirements, health plan contracts, accreditation standards, and applicable state and federal regulations.
• Support internal and external audits by maintaining accurate documentation and providing requested records and reporting.
• Assist with health plan reporting, utilization management metrics, quality initiatives, and operational performance monitoring.
• Identify opportunities to improve referral and authorization workflows, reduce administrative barriers, and enhance operational efficiency.
• Maintain confidentiality and exercise appropriate discretion when handling protected health information and sensitive clinical information.