Utilization Management Specialist

Jamestown Salish Seasons is seeking a Utilization Management Specialist (UMS) to support insurance coordination, utilization management, authorization processes, provider credentialing, and revenue cycle operations within our residential behavioral health program.

This role serves as a key internal resource for insurance and billing operations while supporting continuity of care and program sustainability. The UMS works collaboratively with clinical, operational, and administrative teams to ensure timely authorizations, accurate reimbursement processes, and compliance with regulatory and payor requirements.

The ideal candidate is highly organized, detail-oriented, and experienced in healthcare operations, insurance workflows, and behavioral health environments. This position contributes to a trauma-informed, recovery-oriented, and culturally respectful environment aligned with the mission and values of the Jamestown S’Klallam Tribe.

At JSS, we are committed to providing compassionate, culturally respectful, and recovery-oriented care in a supportive residential setting. Team members play an important role in supporting both resident wellness and organizational sustainability.

Essential Functions

Utilization Management & Insurance Coordination

• Serve as an internal resource regarding insurance coverage, authorizations, and utilization management requirements
• Coordinate with Managed Care Organizations (MCOs), commercial insurance companies, and other payors regarding treatment authorizations and continued stay reviews
• Support timely submission of clinical and administrative documentation to maintain authorization compliance
• Assist with denial management activities, including scheduling peer-to-peer reviews and facilitating communication between providers and payors
• Monitor authorization status and communicate updates to appropriate team members

Revenue Cycle Support

• Coordinate insurance verification, authorization tracking, claims submission, and payment posting within the electronic health record (EHR) system
• Monitor claims, denials, payment variances, and reimbursement trends
• Identify and resolve issues contributing to payment delays, denials, or revenue cycle inefficiencies
• Collaborate with internal teams and external partners to support efficient reimbursement processes
• Ensure billing and documentation processes comply with regulatory, organizational, and payor requirements

Provider Credentialing & Compliance

• Coordinate provider credentialing, recredentialing, and enrollment activities
• Monitor provider licensure, DEA renewals, and related credentialing requirements
• Maintain accurate credentialing and compliance records

Operational Support & Team Collaboration

• Train and support staff on insurance, authorization, and billing workflows
• Provide backup support for referral coordination and front desk operations as needed
• Maintain accurate and timely documentation related to insurance and billing coordination
• Participate in meetings, trainings, and quality improvement initiatives
• Communicate professionally with residents, families, payors, and community partners

Qualifications

Required

• Minimum of three (3) years of experience in:
• Utilization management
• Insurance authorization
• Medical billing
• Revenue cycle operations
• Provider credentialing
• Healthcare administration or related healthcare operations
• Knowledge of:
• Utilization management processes
• Insurance authorization requirements
• Claims submission and payment posting
• Revenue cycle operations
• Provider credentialing workflows
• Proficiency with EHR systems, billing software, payor portals, and standard office technology
• Strong organizational, communication, and problem-solving skills
• Ability to manage multiple priorities in a fast-paced environment
• Understanding of HIPAA, 42 CFR Part 2, and confidentiality requirements
• Valid driver’s license
• Ability to pass a criminal background investigation

Preferred Qualifications

• Associate degree in healthcare administration, business, accounting, medical office administration, or related field
• Experience working in behavioral health, residential treatment, psychiatric, substance use disorder, or inpatient healthcare settings
• Experience with provider credentialing and payor enrollment processes
• Experience training staff on operational and billing workflows
• Experience working with tribal health programs, tribal communities, or underserved populations
• Understanding of culturally responsive and recovery-oriented care practices

Additional Information

• Employment is contingent upon successful completion of a criminal background investigation