Top 154 Provider clinical quality specialist Jobs in Columbus

Utilization Management Specialist
ST VINCENT FAMILY SERVICES —Columbus, OH
- Weekends as needed
- Hybrid work
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Paid time off
- 401(k) matching
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Quality Improvement Specialist
PrimaryOne Health —Columbus, OH
- RN License
- Mid-level
- Travel
- Paid holidays
- Disability insurance
Fraud and Abuse Investigator / CPC - Remote
Sentara Workforce Solutions, LLC —Columbus, OH
- $25.60 - $42.67 an hour
- Overtime
- Remote
- Mid-level
- Bachelor's degree
- 2 years
- 403(b) matching
- Paid parental leave
Quick Apply
4d
Clinical Specialist
PROCEPT BioRobotics Corporation —Columbus, OH
- $108,000 a year
- Full-time
- Bachelor's degree
- Operating room
- Travel
- Opportunities for advancement
Quick Apply
10d
Appeals and Grievances Specialist
Sidecar Health —Columbus, OH
- $65,000 - $75,000 a year
- Remote
- Mid-level
- 3 years
- Analysis skills
- Paid holidays
- Health insurance
Quick Apply
10d
Client Insurance Specialist
Integrated Services for Behavioral Health —Columbus, OH
- $20.97 - $24.56 an hour
- Hybrid work
- Mid-level
- Organizational skills
- 2 years
- Disability insurance
- Health insurance
Quick Apply
Health Information Management Specialist
Equitas Health, Inc. —Columbus, OH
- Weekends as needed
- Hybrid work
- HIPAA
- Research
- Mid-level
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Primary Care Provider
Hometown Urgent Care —Groveport, OH
- Full-time
- Internal Medicine
- Primary Care
- Mid-level
- Health savings account
- Health insurance
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Program Manager, Therapeutic & Pre-school Educational Services
St. Vincent Family Center —Columbus, OH
- $60,000 - $70,000 a year
- Full-time
- Microsoft Outlook
- Customer service
- LPC
- Health savings account
- Health insurance
Quick Apply
Family Centered Treatment Specialist
HEALTH CONNECT AMERICA, INC —Dublin, OH
- Full-time
- Mid-level
- Office
- Bachelor's degree
- Health savings account
- Paid holidays
Quick Apply
6d
Virtual Hiring Event: Registered Nurses & Registered Nurse Care Coordinators
Ohio State University Physicians, Inc. —Columbus, OH
- $32.85 - $48.55 an hour
- Part-time
- CPR Certification
- Nursing
- RN License
- Wellness program
- Continuing education credits
5d
Speech-Language Pathologist (SLP)
Healthpro Heritage, LLC —Dublin, OH
- Part-time
- Mid-level
- Home Health
- Communication skills
- Dental insurance
- 401(k)
Therapist ( Ohio) (LPCC/LISW)
Boulder Care —Ohio
- $85,000 - $115,000 a year
- Full-time
- Remote
- Background check
- Addiction Medicine
- 5 years
- Paid parental leave
- Paid holidays
7d
RN - Clinical Program Coordinator
OhioHealth —Columbus, OH
- Full-time
- Nursing
- RN License
- Mid-level
Clinical Reviewer - Medical Coder & QA
Ohio Living —Westerville, OH
- Full-time
- Nursing
- Microsoft Excel
- English
Quick Apply
Assessment Specialist, Behavioral Health
Columbus Springs East —Columbus, OH
- $25.89 - $34.96 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Quick Apply
Medical Assistant Apprentice- Interest Pool
Ohio State University Physicians —Columbus, OH
- Full-time
- 18 years or older
- Vital signs
- HIPAA
- Wellness program
- Paid holidays
10d
Registered Nurse (RN) Care Coordinator- Hepatology-Main Campus
Ohio State University Physicians —Columbus, OH
- $32.85 - $48.55 an hour
- Full-time
- Hybrid work
- CPR Certification
- Nursing
- RN License
- Wellness program
- Paid holidays
Lead Medical Assistant- Internal Medicine
Ohio State University Physicians —Columbus, OH
- $22.09 - $33.13 an hour
- Full-time
- 7 years
- BLS Certification
- Internal Medicine
- Wellness program
- Paid holidays
Sales Onboarding Specialist
Option Care Enterprises, Inc. —Columbus, OH
- $53,339.06 - $88,898.44 a year
- Full-time
- Microsoft Excel
- Marketing
- Mid-level
- Health savings account
- Health insurance
Quick Apply
7d

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provider clinical quality specialist jobs near columbus

Utilization Management Specialist

ST VINCENT FAMILY SERVICES
Columbus, OH

Quick Apply

Job Details

Full-time

Benefits

Paid time off
401(k) matching

Qualifications

Associate's degree

Full Job Description

At St. Vincent Family Services, it's our job to help families build bright futures. Make it your job, too!

We offer competitive compensation based on education, experience, licensure, and internal equity, along with comprehensive benefits, 401(k) matching, and a generous PTO package.

These are just a few of the many reasons to join our team.

SUMMARY

The Utilization Management Specialist is responsible for coordinating and managing all prior authorization activities for clinical services across multiple Medicaid Managed Care Organizations (MCOs). This position serves as the primary liaison between St. Vincent Family Services and MCO payors to ensure authorization requests are submitted timely, approved services are tracked accurately, and service disruptions are prevented.

The Utilization Management Specialist monitors client eligibility, tracks authorized units by procedure code, manages authorization renewals, and communicates authorization approvals and denials to treatment teams. This role works closely with clinical staff, program leadership, billing, and MCO representatives to maximize reimbursement, ensure compliance with payer requirements, and support continuity of care for clients.

ESSENTIAL DUTIES & RESPONSIBILITIES

Maintains confidentiality and compliance with HIPAA, agency policies, and payer regulations.
Serves as the primary point of contact for all MCO prior authorization activities.
Monitors and reviews MCO portals to track authorization status, pending requests, approvals, denials, and requests for additional information.
Verifies and documents client eligibility and insurance coverage prior to authorization submission and throughout treatment episodes.
Runs authorization utilization reports and analyzes data to identify clients approaching authorization thresholds.
Maintains an authorization tracking system that includes:
- Authorization numbers
- Approved dates of service
- Procedure codes
- Authorized units
- Units utilized
- Remaining units
- Expiration dates
Monitors service utilization and proactively identify clients nearing authorized unit limits.
Requests completed clinical documentation and authorization forms from treatment providers when renewal thresholds are met.
Reviews authorization packets for completeness and accuracy prior to MCO submission.
Submits initial, concurrent, and reauthorization requests to Medicaid Managed Care Organizations within required timelines.
Coordinates responses to MCO requests for additional documentation or clinical information.
Communicates authorization approvals, denials, partial approvals, and service changes to treatment team members in a timely manner.
Collaborates with program directors, treatment providers, and billing staff to resolve authorization concerns and prevent service interruptions.
Maintains organized electronic records of all authorization submissions, determinations, and correspondence.
Tracks authorization denial patterns and communicates trends to leadership.
Assists with audits, quality assurance activities, and compliance reviews related to authorization management.
Develops and maintains productive working relationships with MCO representatives.
Participates in department meetings, training, and process improvement initiatives.
Performs other duties as assigned.

QUALIFICATIONS

Education and/or Experience:

Associate's Degree required; Bachelor's Degree preferred in Healthcare Administration, Business Administration, Social Work, Public Health, or related field.
Minimum of two years of experience in healthcare authorization management, utilization management, medical billing, behavioral health administration, or related healthcare setting preferred.

Knowledge, Skills & Abilities:

Strong understanding of behavioral health authorization processes and payer requirements.
Knowledge of Medicaid and Managed Care authorization procedures preferred.
Excellent organizational skills and attention to detail.
Strong analytical skills and ability to interpret utilization and authorization reports.
Ability to manage multiple deadlines and competing priorities.
Ability to communicate effectively with clinical, administrative, and payer representatives.
Ability to maintain accurate records and follow complex payer requirements.
Ability to work independently while functioning as part of a collaborative team.

Technical Skills

Proficiency in Microsoft Outlook, Excel, Word, and Teams.
Ability to learn and navigate multiple MCO portals.
Experience with electronic health records and data management systems.
Ability to generate, analyze, and maintain utilization tracking reports.

WORK ENVIRONMENT

Standard office environment with occasional evenings/weekends for events. Hybrid schedule available after 90-day probationary period.

Requires prolonged sitting and extensive computer use.
Requires manual dexterity sufficient to operate a computer, telephone, and other office equipment.
Requires normal range of hearing and vision to prepare reports and communicate effectively.
May occasionally lift and/or move items up to 15 pounds.

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Refine Your Search

provider clinical quality specialist jobs in columbus

Utilization Management Specialist

Quality Improvement Specialist

Fraud and Abuse Investigator / CPC - Remote

Clinical Specialist

Appeals and Grievances Specialist

Client Insurance Specialist

Health Information Management Specialist

Primary Care Provider

Program Manager, Therapeutic & Pre-school Educational Services

Family Centered Treatment Specialist

Virtual Hiring Event: Registered Nurses & Registered Nurse Care Coordinators

Speech-Language Pathologist (SLP)

Therapist ( Ohio) (LPCC/LISW)

RN - Clinical Program Coordinator

Clinical Reviewer - Medical Coder & QA

Assessment Specialist, Behavioral Health

Medical Assistant Apprentice- Interest Pool

Registered Nurse (RN) Care Coordinator- Hepatology-Main Campus

Lead Medical Assistant- Internal Medicine

Sales Onboarding Specialist

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