UM Authorization Analyst 1

Join a team where your clinical insight directly shapes patient outcomes and care quality. As a UM Authorization Analyst, you’ll play a critical role in ensuring timely, evidence-based decisions that support both patients and providers—while working in a collaborative environment that values accuracy, efficiency, and professional growth.

JOB PURPOSE AND SUMMARY:

The UM Authorization Analyst is responsible for overseeing the procedure authorization team to ensure accurate processing of medical procedure authorizations. This role involves streamlining processes, ensuring compliance with regulations, and liaising with healthcare providers and insurance companies.

This role can be worked remotely from anywhere in the contiguous United States. It will be working on an Eastern time schedule.

ESSENTIAL DUTIES AND RESPONSBILITIES:

• Live and exemplify TOI core values, providing outstanding customer service and promoting a positive experience for patients and staff members.
• Oversee the review and processing of procedure authorization requests.
• Ensure all the authorizations are obtained before services are rendered, in compliance with payer requirements.
• Maintain accurate and up-to-date records of all authorization requests and decisions.
• Ensure compliance with all relevant regulations, policies, and guidelines related to medical procedure authorizations.
• Serve as a liaison between healthcare providers, patients, and insurance companies to facilitate the authorization process.
• Address and resolve any issues or concerns raised by providers or patients regarding authorizations.
• Collaborate with other departments, such as billing and patient services, to ensure a seamless patient experience.
• Analyze data to identify trends, areas for improvement, and potential process enhancements.
• Implement changes based on data analysis to improve the efficiency and effectiveness of the authorization process.
• Identify and forward standard or expedited appeals to the appropriate health plan.
• Stay current on industry regulations, guidelines, and best practices related to utilization management and review.
• Perform other duties as assigned to support operational goals.
• Participate in monitoring and analyzing Inter-Rater Reliability (IRR) testing, identifying trends, and recommending best practice improvements to consistent decision-making.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Excellent communication and interpersonal skills.
• In-depth knowledge of medical procedure authorization processes and healthcare insurance requirements.
• Ability to analyze data and implement process improvements.
• Proficiency with medical billing software and electronic health records (EHR) systems.
• Strong organizational skills and attention to detail.
• Strong understanding of evidence-based guidelines (MCG, National Coverage Determinations, Local Coverage Determinations).
• Understanding of prior authorization regulatory requirements and turnaround time expectations (CMS, AHCA, NCQA, URAC).

REQUIRED EXPERIENCE, EDUCATION, AND/OR TRAINING:

• High School Diploma or equivalent. Associates degree preferred.
• Minimum of 3-5 years of experience in medical authorizations.

PHYSICAL WORKING REQUIREMENTS:

The position involves prolonged periods of sitting at a desk, extensive computer use, and phone interaction. Additionally, the role may require occasional lifting of up to 20 pounds for office supplies or equipment.

The physical demands described above are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.