Job Description

Responsibilities

The Utilization Review/Utilization Management (UR/UM) Specialist is responsible for reviewing medical services for appropriateness, medical necessity, and efficiency. This role ensures that patient care aligns with established guidelines and payer policies while optimizing resource utilization. The specialist collaborates with healthcare providers, insurance companies, and case management teams to facilitate timely authorizations and appeals when necessary.

Qualifications

Education:

• Associate's or Bachelor's degree in Radiation Therapy, Health Administration, or a related field preferred; 2-5 years oncology experience; utilization review or prior authorization experience required.

Experience:

• 2-5 years in utilization review, case management, or prior authorization, preferably in a hospital or managed care setting.
• Strong understanding of medical necessity criteria, insurance policies, and reimbursement guidelines.
• Proficiency in electronic medical records (EMR), payer portals, and utilization management software.
• Excellent communication and problem-solving skills.
• Ability to work independently and manage multiple cases simultaneously.
• Knowledge of regulatory requirements (e.g., Medicare, Medicaid, commercial insurance).

Pay Range

USD $29.89 - USD $42.74 /Hr.

Our Commitment to Health and Equal Opportunity

Our Legacy is good for health for Our People, Our Patients, Our Communities, Our World. Above all, we will do the right thing.

If you are passionate about our mission and believe you can contribute to our team, we encourage you to apply—even if you don't meet every qualification listed. We are committed to fostering an inclusive environment where everyone can grow and succeed.

Legacy Health is an equal opportunity employer and prohibits unlawful discrimination and harassment of any type and affords equal employment opportunities to employees and applicants without regard to race, color, religion or creed, citizenship status, sex, sexual orientation, gender identity, pregnancy, age, national origin, disability status, genetic information, veteran status, or any other characteristic protected by law.

To learn more about our employee benefits click here: www.legacyhealth.org/For-Health-Professionals/careers/benefiting-you