Utilization Management Specialist

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Employees can work remotely
  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group’s over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.

Job Description

Essential Job Duties and Responsibilities:


  • Responsible for receiving, accurately logging and responding to all inquiries and submissions for 1st level provider appeals according to department policy and procedure
  • Assist Nurse Manager for Adverse Determinations and Appeals in compiling clinical information for all denials and 1st level provider appeals
  • Work with facility staff to generate clear and concise adverse determination and appeal letters in accordance with style guide/departmental policies and procedures
  • Familiar with the various MAC's and their LCD's and Billing & Coding Articles.
  • Ability to articulate adverse determination decision to department lead/manager with support to validate next action.
  • Ensure timely response to denials and 1st level provider appeals.
  • Provide regulatory and payer policy guidance for denials and appeals at all levels
  • Facilitate communication with internal business stakeholders and provide support related to denials management process
  • Provide support to HealthHelp’s undergoing audits
  • Provide exemplary audit support to Medical Directors
  • Provide reports and analysis of data to Department manager at regular intervals.
  • Assist in developing training materials and best practice
  • Provide education and training to business stakeholders as requested


Overview of Position: Is responsible for denials and appeals management in accordance with established policies, procedures and practices of the company under the direction of the Chief Medical Officer.  (For reference, sample posting this was pulled from had this position reporting into the SVP for Compliance)

Essential Qualifications:
•    Bachelor of Science or Arts Degree, pre-med track/Biology.
•    Strong grasp of clinical terminology across all disciplines
•    Excellent organizational and leadership abilities
•    Outstanding communication and people skills
•    Basic computer skills

Desired Qualifications:
•    2 years’ experience utilization management
•    Experience in appeal letter writing and denials management
•    Experience with managed care
•    In-depth knowledge of industry rules and regulations
•    Familiarity with Microsoft Office
•    Capacity to grasp new theories and principles and implement them in practice
•    Ability to educate staff in a manner that is conducive to learning and implementation
•    Good customer service and problem resolution skills.
•    Strong knowledge in Medicare and Medicaid Denial and Appeal determination documentation.

Additional Information

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