Education and Experience Required: High school diploma or equivalent; Associate’s degree or certification in a healthcare-related field preferred. Preferred: Bachelor’s degree in healthcare administration, nursing, or a related field. 2+ years of experience in Utilization Review, case management, or a similar healthcare operations role. Knowledge Knowledge of Utilization Review processes and payer requirements. Familiarity with healthcare systems, electronic medical records (EMR), and clinical documentation standards. Understanding of healthcare regulations, including Medicare and Medicaid guidelines. Skills Strong organizational skills to manage multiple tasks and meet tight deadlines. Excellent written and verbal communication skills for professional interactions with clinical staff, payers, and clients. Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and familiarity with UR-related software. Attention to detail to ensure the accuracy of documentation and review submissions. Ability to work independently while collaborating effectively within a remote team environment. Work Context Remote work environment requiring consistent, reliable communication with team members and stakeholders. May involve occasional travel for team meetings or client-related events. Primary Job Duties The essential functions include, but are not limited to the following: Coordination: Manage and track the submission of clinical reviews to payers, ensuring deadlines and requirements are met. Payer Communication: Act as the primary liaison with payers to address and resolve any issues related to utilization reviews. Documentation: Ensure that clinical documentation and review requests are accurate, complete, and compliant with payer guidelines. Team Support: Collaborate with utilization nurses and other team members to ensure seamless operations. Compliance: Maintain knowledge of payer guidelines and healthcare regulations to ensure all activities meet compliance standards. Process Improvement: Identify and implement opportunities to streamline UR workflows and improve operational efficiency. Client Service: Provide exceptional service to clients by addressing inquiries, resolving issues, and ensuring satisfaction with UR operations.