Utilization Review And Preauthorization Specialist

About the Alliance Coal Health Plan

The Alliance Coal Health Plan is a single employer health plan established for the benefit of the employees and dependents of Alliance Resource Partners, L.P. (ARLP). The Health Plan is committed to supporting the health and well-being of our workforce through high-quality, cost-effective care.

Alliance Resource Partners, L.P. is a leading producer and marketer of coal and owner of mineral and royalty interests. ARLP is committed to providing reliable energy while maintaining a strong focus on employee safety and environmental responsibility.

Position Summary

The Utilization Review and Preauthorization Specialist plays a critical role in evaluating medical services for medical necessity, benefit eligibility, and compliance with plan guidelines before care is provided. As a key member of the Utilization Review team, this role ensures efficient authorization processing, supports high-quality care outcomes, and promotes compliance with regulatory standards. The Specialist serves as a central point of communication between healthcare providers, members, and internal departments.

Key Responsibilities

Authorization Processing & Utilization Review

• Review and process prior authorization requests for outpatient services, imaging, procedures, medications, and DME.
• Verify member eligibility and coverage based on plan guidelines.
• Apply clinical criteria (e.g., MCG) to determine medical necessity.
• Approve or escalate requests in accordance with clinical protocols.
• Collaborate with Medical Directors or Nurse Managers on complex or high-cost cases.
• Ensure accurate documentation of authorization decisions and rationale.

Communication & Customer Service

• Communicate decisions professionally and within required timeframes to providers and members.
• Provide compassionate, responsive support for provider and member inquiries.
• Educate providers and internal teams on plan requirements and documentation standards.
• Resolve authorization-related issues and escalate when necessary.

Compliance & Documentation

• Maintain compliance with HIPAA, URAC, NCQA, and internal plan policies.
• Monitor turnaround times to ensure regulatory adherence.
• Maintain detailed, accurate records of all authorization activity.

Collaboration & Operational Support

• Coordinate with Care Coordination, Case Management, Claims, and Customer Service teams.
• Contribute to quality improvement efforts and share utilization trends with leadership.
• Support policy and workflow enhancements through insights from day-to-day operations.

Qualifications

Education & Experience

• Associate or bachelor's degree in a healthcare-related field preferred.
• Licensed Practical Nurse (LPN) preferred; CMA or other clinical certifications with relevant experience will be considered.
• At least 2 years of experience in utilization review, preauthorization, or a related healthcare setting.
• Familiarity with MCG, InterQual, or similar clinical guidelines preferred.
• Working knowledge of CPT, HCPCS, and ICD-10 coding is strongly preferred.

Skills & Competencies

• Excellent critical thinking and clinical interpretation skills.
• Strong written and verbal communication.
• Detail-oriented with the ability to manage multiple priorities.
• Proficiency in Microsoft Office (Word, Excel, Outlook) and electronic utilization systems required.

Working Conditions

• Full-time, in-office position.
• Standard business hours: 8:00 AM - 5:00 PM, Monday through Friday.

Benefits Overview

• No-cost health insurance for employees and their families (no premiums, deductibles, coinsurance, or copays for in-network services).
• Access to a 100% covered on-site clinic for employees and dependents.
• 401(k) plan with up to 8% employer contributions.
• Eligibility for an annual discretionary bonus.
• Comprehensive dental, vision, and life insurance.
• Health and dependent care flexible spending accounts.

Ready to join a team that prioritizes high-quality care, operational excellence, and the well-being of our members? Apply today and be part of a mission-driven health plan serving the employees and families of Alliance Resource Partners.