Required Qualifications:

• Bachelor’s degree in healthcare administration, or a related field or a combination of equivalent education, experience, and training
• Minimum three years of experience in utilization management, care coordination, or a similar role within a healthcare setting
• Experience processing ambulatory commercial, Medicare Fee for Service, Medicare Advantage prior authorizations
• Working knowledge of HMO referral process, eligibility verification, and health plan benefit interpretation
• Strong understanding of healthcare networks, referral processes, and out-of-network utilization strategies 
• Demonstrated data analytical skills
• Strong organizational, data analytical, and problem-solving skills and proficient in MS Excel
• Team orientation and ability to work effectively across functional areas of the company
• Ability to work independently utilizing company established processes

Preferred Qualifications:

• Provider contracting experience
• Minimum three years of experience working in a Managed Care environment
• Experience reviewing and understanding Commercial and Medicare benefits and COB determination, DOFR interpretation and the application of Medicare Guidelines