WHO WE ARE
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
The Lead Utilization Management (UM) Coordinator provides operational leadership and oversight for the Utilization Management Coordinator team while supporting the coordination, processing, and administrative functions of the utilization review process. This role serves as a subject matter expert, ensuring timely, accurate, and compliant processing of authorization requests in accordance with established clinical guidelines, regulatory requirements, and organizational policies. The Lead UM Coordinator partners closely with UM nurses, physicians, leadership, providers, and other healthcare professionals to promote workflow efficiency, quality outcomes, and exceptional customer service.
Key Responsibilities
- Lead the daily operations and workflow of the UM Coordinator team to ensure timely processing of authorization requests.
- Serve as the primary resource and subject matter expert for UM Coordinators, providing guidance, coaching, and support on complex cases and operational issues.
- Assist leadership with onboarding, training, mentoring, and ongoing development of new and existing UM Coordinators.
- Monitor team productivity, work queues, turnaround times, and workload distribution to ensure compliance with regulatory and organizational standards.
- Receive, review, and process incoming requests for authorization of medical services.
- Coordinate with providers, members, and internal clinical staff to obtain required documentation for utilization reviews.
- Enter authorization requests, updates, and determinations into the utilization management system accurately and efficiently.
- Track and monitor pending authorizations to ensure timely processing and communication of decisions.
- Collaborate with UM nurses and physicians to facilitate medical necessity reviews and ensure adherence to clinical guidelines.
- Communicate authorization determinations (approvals, modifications, or denials) to providers and members within required regulatory timeframes.
- Perform quality reviews of authorization documentation and identify opportunities for process improvement.
- Assist leadership with audits, regulatory readiness, accreditation activities, and quality improvement initiatives.
- Escalate complex operational or system issues to management and recommend process improvements to enhance efficiency and service quality.
- Act as a liaison between internal departments, providers, health plans, and external vendors to resolve issues and improve collaboration.
- Assist with reporting, metrics tracking, and monitoring of key performance indicators (KPIs).
- Promote compliance with NCQA, CMS, state and federal regulations, health plan requirements, and organizational policies.
- Maintain strict adherence to HIPAA and confidentiality standards.
Education & Experience
- High School Diploma or equivalent required; Associate's degree in Healthcare Administration or a related field preferred.
- Minimum of 3–5 years of experience in a health plan or managed care environment.
- At least 2 years of Utilization Management, Prior Authorization, or Case Management support experience required.
- Previous experience serving as a team lead, trainer, mentor, or in an informal leadership role strongly preferred.
- Demonstrated ability to interpret health plan benefits and authorization guidelines.
- Bilingual (English/Spanish) required.
- Medical Assistant certification or other healthcare certification preferred.
Skills & Competencies
- Advanced knowledge of medical terminology, utilization management, prior authorization, and healthcare benefit processes.
- Strong understanding of regulatory and accreditation requirements, including NCQA, CMS, HIPAA, and health plan standards.
- Proficiency with Microsoft Office Suite and utilization management platforms (e.g., MCG, InterQual, or similar UM systems).
- Excellent leadership, coaching, mentoring, and team-building skills.
- Strong analytical, organizational, and problem-solving abilities.
- Outstanding written and verbal communication skills.
- Ability to prioritize multiple assignments and meet regulatory turnaround times in a fast-paced environment.
- Strong attention to detail and commitment to quality and compliance.
- Ability to work independently while supporting team performance and operational excellence.
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
