Utilization Management Specialist

About Us

Kaizen Clinical Partners, Inc. (KCP) is a group of experienced, dedicated, and passionate physicians and clinics, delivering equitable, excellent, and efficient primary and preventive care. Our mission is to create a sustainable healthy society by improving well-being in our communities. We believe in treating our patients and staff with the highest ethical standards and care. KCP has a strong commitment to creating a legacy of how health care should be, focusing on our patients' needs, implementing the best service delivery ideas, and enhancing the patient experience. Most of our primary care clinics have been serving the Rio Grande Valley for more than 20 years.

Job Summary: The Utilization Management (UM) efforts for patients include improved access to care, better outcomes, and lower overall costs. KCP is seeking a highly organized and experienced Utilization Management Specialist to ensure the necessity and appropriateness of care.

Responsibilities:

Duties include, but are not limited to:

• Analyze electronic medical records.
• Focus on evaluating the utilization of healthcare services, treatments, and procedures.
• Utilize retrospective reviews and other UM tools to identify opportunities for improvement and optimize patient treatment plans accordingly.
• Ensure that the services provided are medically necessary, cost-effective, and aligned with established guidelines.
• Coordinate and communicate with all clinical professionals involved with patients regarding pertinent information needed for medical review.
• Understand the language of contracts and recommend changes as necessary.
• Work with physician and applicable staff to review orders regarding consults, exams, DME, etc. to ensure compliance with the patient’s insurance company.
• Maintain internal tracking documents and spreadsheets as required.

The successful candidate will be flexible and adapt to changes in policies and procedures, new techniques, and additional responsibilities as assigned to meet changing business and healthcare needs. This candidate will be personable and have strong communication skills, excellent organizational abilities, and a proven track record of conducting thorough medical reviews.

Requirements:

• Associate or Bachelor’s degree in a medical or health-related field is preferred
• Extensive background in medical billing or health care quality assurance is preferred
• Previous experience in medical utilization review required
• Familiarity with medical coding standards and procedures; Know how to interpret medical records and industry journals.
• Excellent communication and interpersonal skills
• Strong organizational and time-management abilities
• Ability to work independently and as part of a team
• Detail oriented
• Proficient in Microsoft Office and other office software, including EMRs
• Familiar with healthcare regulatory requirements

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Supplemental pay types:

• Bonus opportunities

Ability to Relocate:

• McAllen, TX 78501: Relocate before starting work (Required)

Work Location: In person