Utilization Mgmt Specialist (Hybrid/Troy, MI) - Health ...

General Summary: u201cUnion Represented Positionu201d providing essential administrative, authorization and organizational support to the daily operations of utilization management, care management or quality teams. This role will ensure smooth and efficient work by supporting, managing documentation, processing utilization management requests and facilitating cross-departmental communication. This position would be required to communicate with provider and members in a friendly and professional manner. Supporting all departmental activities related to the specific team aligned with. The following job duties may vary depending on the specific team being supported. Principal Duties and Responsibilities: + Receive and process utilization management inquiries via the phone queue and fax, which may include authorizations or appeals. Review requests for accuracy and assist with diagnostic and procedure coding utilizing CPT, HCPC and ICD-9/10 codes according to departmental standards. + Respond, research and provide support promptly to provider's/memberu2019s requests and inquiries. Educate providers and members on benefit provisions and HAP policies and procedures. Contact providers/members to obtain information required. + Work directly with specific team aligned to regarding issues/outreach and urgent requests at the request of providers and members. Document in the appropriate platform based on workflow and regulatory requirements. + Type, process, mail, file and scan denial letters or any other materials and or correspondence/letters to members/ providers according to NCQA, CMS and DOL or any other standards and timeframes. Maintain daily log of denial activities. + Receive, filter and enter discharge data from the daily report and collaborate with facilities to obtain discharge dates for timely claims payment. + Receive email, gather and send member information for subpoena requests from the Legal department. + Retrieve, investigate, conduct research, label and attach the faxed clinical information into the care management software. + View, investigate, assist in monitoring and resolve and/or route to correct team cases assigned in the customer service software. + Retrieve messages on the after-hour voicemail and complete the log daily to remain compliant with NCQA standards. + Receive emails, referrals, phone or faxed requests, enter case into care management software and notify appropriate team for processing. + Support meetings and projects through material preparation, schedule coordination, and active participation. + Assist in workflows including requesting medical records, service reminders to ensure members and providers are completing tests and screenings impacting Hedis/Star measures. + Assist in monitoring work plans and process flows to ensure completion on tasks associated with various projects. + Assist leadership team with reviewing and sharing reports with the applicable team members and monitoring of compliance, as needed. + Perform all other related duties as assigned. Education/Experience Required: + Associateu2019s degree or a minimum of four (4) years of related experience may be considered in lieu of degree. + Minimum of two (2) years of recent administrative experience in a health care setting within the last three years. + Minimum of two (2) years of recent experience providing direct communication to customers and/or providers within the last two years. + Demonstrated proficiency with MS Word and Excel. + Knowledge of basic medical terminology. + Knowledge of ICD-9, CPT, and HCPC codes. + Knowledge of hospital, HMO, and health care related procedures. + Billing or coding experience preferred. Skills and Abilities: + Customer-focused. + Excellent telephone skills + High degree of organizational skills. + Detail oriented. + Good verbal and written skills. + Self-motivated and self-directed. Additional Information + Organization: HAP (Health Alliance Plan) + Department: Behavioral Health + Henry Ford Health Location: HAP (Health Alliance Plan) + Shift: Day Job + Union Code: Office/Non-Exempt, HAP Additional Details This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above. Overview Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services u2013 from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Fordu2019s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nationu2019s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at /careers . Benefits The health and overall well-being of our team members is our priority. Thatu2019s why we offer support in the various components of our teamu2019s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits. Equal Employment Opportunity/Affirmative Action Employer Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.

Created: 2026-04-20