Lead Utilization Management Correspondence

Job Summary

The Lead Utilization Management (UM) Correspondence reviews, process and corresponds to all incoming correspondence related to UM decisions. This position helps the UM correspondence team in processing complex and time-sensitive authorization requests to ensure correspondence is compliant with regulatory standards and to L.A. Care’s policy guidelines and the federal and state regulatory agencies.

This position leads and collaborates closely with assigned team daily. This role will mentor, coach, and provide feedback to management on performance of staff. Ensure team effectiveness and project completion.

Duties

Lead the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Assist management in overseeing the daily office workflow and recommends enhancements to process and procedures. Provide team guidance on escalations and resolve internally if appropriate. (20%)

Help oversee the team process incoming cases through system on UM determinations letters through completion. Monitor the team's data entry to ensure all information is correct and complete. (10%)

Accurately input details for member and provider correspondence into the UM system, tracking case status and ensuring proper documentation throughout the process. (10%)

Identify and resolve discrepancies or issues related to authorization requests. Maintain accuracy and compliance while working under tight deadlines. Manage and process complex authorization requests. (10%)

Draft and send clear, concise, and compliant responses to member and providers, including explanations for approvals, denials, and requests for further documentation. (10%)

Ensure that all correspondence and documentation meet strict requirements from regulatory and accreditation bodies like the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA), and with contractual obligations and within L.A. Care’s standards. Monitor and respond to inquiries in UM Correspondence Inbox. (10%)

Responsible for the quality assurance of all correspondence before it is sent. This includes reviewing letters for clarity, accuracy, and adherence to regulatory requirements. Collaborate with clinical team to ensure all necessary information is gathered to help timely decision-making. (10%)

Work with cross-functional teams in navigating complex cases and regulatory requirements while reinforcing adherence to best practices in UM processes. Ensure the team adheres to required turnaround times for all authorization and denial letters to prevent violations. (5%)

Duties Continued

Maintain and track regular compliance reports detailing authorization activity, correspondence timelines, and performance against regulatory standards at the request of management. Ensure correct documentation and reporting during audits, contributing to the department’s ability to meet compliance goals and maintain regulatory readiness. Maintain accurate tracking of all appeal cases, ensuring timely follow-up and escalation when necessary. (5%)

Perform other duties as assigned. (10%)

Education Required

Education Preferred

Experience

Required:

At least 1 year of experience preparing regulatory compliant correspondence and/or authorization requests within a healthcare environment and at least 6 months of experience in UM correspondence. for prior authorization requests.

At least 3 months of leading a process, program, or staff experience.

Experience in managing time-sensitive and complex UM-related communications to both members and providers, ensuring adherence to federal and state regulatory guidelines (e.g., DHCS, CMS, DMHC, NCQA).

Experience with Medi-Cal, Medicare, and Commercial lines of business.

Experience with audits and preparing regulatory compliance reports.

Preferred:

Experience in mentoring or training teams in UM processes.

Skills

Required:

Ability in processing and drafting accurate authorization-related correspondence such as denials, modifications, delays/extensions, and downgrades.

Advanced technical ability, independent decision-making, and a deep understanding of the UM process.

Advanced knowledge of medical terminology, including ICD-10, CPT, and HCPCS codes.

Strong verbal and written communication skills for creating clear, concise correspondence and providing effective guidance to the team.

Expertise in Microsoft Office Suite, Adobe PDF, and other authorization software.

Excellent organizational, time management, and multitasking abilities.

Exceptional attention to detail with the ability to identify and correct discrepancies in complex correspondence and authorizations.

Strong people skills with the ability to work independently as well as mentor team members.

Customer-oriented, with the ability to manage sensitive authorization-related inquiries.

In-depth knowledge of Medi-Cal, Medicare, and Commercial lines of business as they pertain to authorization processes and UM processes.

Demonstrated ability in handling authorization requests within a managed care environment.

Familiarity with state and federal regulations governing managed care and utilization review procedures.

Knowledge of letter templates, regulatory language, and UM process guidelines

Ability to gather, analyze, and report on data related to team performance and program effectiveness.

Preferred:

Advanced skills in UM authorization management systems (i.e., QNXT, Onbase, CCA), Microsoft Office Suite and Adobe PDF.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Weekends and holidays hours may be required, as well as overtime based on business need and approval.