Utilization Management Extender- Utilization Management

A Brief Overview

The Utilization Management Extender (UME) is a front‑end Utilization Management support role with direct revenue impact, responsible for ensuring that authorization, notification, and utilization workflows are completed accurately and timely to support reimbursement. This role focuses on admission authorizations, level‑of‑care changes, and concurrent review requirements, while validating that all UM actions are properly documented and aligned with payer rules.

What you will do

• Confirm payer receipt and completeness of submitted documentation to prevent downstream denials. Support front‑end Utilization Management workflows by validating admission authorizations, notifications, level‑of‑care changes, and concurrent review requirements.
• Collaborate with the Case Management team to submit, track, and follow determinations for Acentra QIO appeals, ensuring timely and complete documentation.
• Submit and follow up on Notifications of Admission (NOA), level‑of‑care changes, and concurrent clinical submissions when authorization gaps are identified post‑discharge.
• Reconcile authorization activity throughout the patient stay to ensure required UM actions are completed and accurately documented.
• Manage UM‑related Discharged Not Billed (DNB) work queues by identifying and resolving authorization‑related barriers to claim release.
• Validate authorization details (payer, facility, level of care, length of stay, dates of service) to ensure billing readiness.
• Remove UM‑related billing holds by correcting missing, incomplete, or inconsistent authorization documentation.
• Perform denial avoidance reviews for high‑risk and high‑dollar accounts and identify authorization‑related trends impacting reimbursement.
• Submit, reconcile, and follow up on required notifications (e.g., NOA, OBS‑to‑IP conversions, concurrent reviews) when gaps are identified.
• Respond to payer correspondence, medical record requests, and authorization inquiries; confirm receipt and completeness of submitted documentation.
• Maintain clear, detailed documentation of payer communications and authorization activity within Epic.
• Collaborate with Utilization Management, Revenue Integrity, Coding, HIM, Billing, and Patient Access teams to resolve discrepancies.
• Track, trend, and report authorization and UM workflow issues using dashboards and work queues.
• Escalate complex authorization or payer issues to UM leadership or Physician Advisors as appropriate.
• Provide feedback and education to internal teams regarding documentation or process gaps contributing to denials or delays.
• Participate in audits, meetings, and process improvement initiatives related to UM and revenue cycle performance.

Education Qualifications

• High School Diploma or GED

Experience Qualifications

• Experience supporting Utilization Management operations, including authorization procurement, payer portal use, notification of admission submission, payer outreach, DNB work queues, post discharge reconciliation, and utilization related voicemail management. Knowledge of CMS, AHCA, and managed care authorization requirements, with experience collaborating across Coding, HIM, Billing, or Revenue Integrity teams and working in Epic Resolute or other revenue cycle-related Epic modules.

Skills and Abilities

• Knowledge of front‑end Utilization Management workflows, including admission notifications, authorization initiation, level‑of‑care changes, and concurrent review support.
• Understanding of how authorization accuracy and timeliness directly impact billing, DNB, and denials.
• Working knowledge of payer authorization requirements, notification timelines, and documentation standards.
• Proficiency with electronic medical records (EMR), including Epic utilization and revenue cycle workflows, and payer portals.
• Ability to interpret payer rules and authorization outcomes to identify financial risk and initiate corrective action prior to claim submission.
• Strong analytical and problem‑solving skills with attention to detail.
• Ability to independently prioritize workload in a fast‑paced, metrics‑driven environment.
• Effective written and verbal communication skills for collaboration with UM, Revenue Integrity, Coding, HIM, Billing, and payers.
• Proficiency in Microsoft Office applications, including Excel.
• Ability to manage confidential patient and financial information in compliance with HIPAA and organizational policies.