About The Role 

• Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization.
• Draft, edit, and format denial and partial denial letters based on authorization determinations, including accurately copying and inserting approved clinical statements, criteria citations, and physician rationale into correspondence templates.
• Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate.
• Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues.
• Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release.
• Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times.
• Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence.
• Review, investigate, and resolve items listed on the failed fax report to ensure timely and successful delivery of correspondence.
• Perform other related duties as assigned.

• High school diploma or GED required.
• Two or more years of healthcare administrative support experience.
• Two or more years of managed care experience, in Utilization Management or Appeals.
• Strong verbal and written communication skills.
• Demonstrated customer service skills, including effective written and verbal communication.
• Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment.
• Ability to adapt quickly to changing business needs and learn new processes and systems.

• Proficient in electronic medical records understanding and medical record documentation.
• 2-4 years’ experience as a medical assistant, office assistant or other clinical experience.
• Previous experience handling/reviewing UM denial letters
• Proficient/Experienced with CPT4 and ICD-10 codes.
• Previous Member Service or Customer Service telephonic experience.