[Hiring] Utilization Management Specialist @Cedars-Sinai

Role Description

The Utilization Management Specialist provides advanced operational and workflow support to Utilization Review (UR) Nurses to ensure timely, accurate, and compliant execution of the utilization review process. This position performs complex, non-clinical functions that directly support payer communication, authorization coordination, documentation integrity, and regulatory compliance.

• Maintain an assigned portfolio of cases in partnership with multiple UR Nurses.
• Accountable for oversight of authorization workflows from initial submission to final determination.
• Apply independent judgment in prioritizing cases based on payer deadlines, regulatory requirements, and authorization expiration risk.
• Ensure documentation and authorization activities are complete, accurate, and executed within established timeframes.
• Support revenue integrity, denial prevention, and compliance with CMS and payer specific requirements.
• Operate in a fast-paced, time-sensitive environment using EPIC/CS-Link, AIDIN, payer portals, and related UM systems.
• Prepare and assemble clinical review packets and supporting documentation for payer submission.
• Review records to confirm required documentation elements are present prior to submission and escalate gaps to the assigned UR Nurse.
• Track submission confirmations and ensure timely follow up on pending payer determinations.
• Manage the authorization lifecycle for assigned cases, including entry, tracking, follow up, documentation of determinations, and monitoring of payer response timelines.
• Monitor payer portals and contact payers directly to obtain authorization updates and resolve status discrepancies.
• Independently prioritize cases based on submission deadlines, authorization expiration risk, and regulatory timeframes.
• Escalate urgent authorization issues, delays, or barriers that may result in avoidable denials or authorization lapses.
• Coordinate peer to peer scheduling logistics and maintain related documentation.
• Document and communicate payer determinations, including approvals, partial approvals, and denials, in EPIC/CS-Link in accordance with departmental and regulatory standards.
• Identify patterns or systemic authorization workflow issues and communicate trends to UM leadership.
• Ensure all required documentation is accurately entered into EPIC/CS-Link in accordance with departmental and regulatory standards.
• Communicate effectively with internal and external partners to ensure patient and authorization information is current and complete.

Qualifications

• High school diploma or GED required.
• Associate's degree or college diploma in business or health or a related field preferred.
• Minimum of 2 years of experience in hospital authorization management, utilization review support, revenue cycle operations, or payer communication processes required.
• Experience independently managing authorization workflows highly preferred.
• Minimum of 2 years of acute care experience preferred.

Requirements

• Approved Remote States: Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, Texas.

Benefits

• Outstanding benefits package including health care.
• Paid time off.
• 403(B) plan.