Utilization Management (UM) Coordinator

About Us:

On a mission to deliver affordable, delightful healthcare for all, First Stop Health provides connected, whole-person virtual care to employers 24/7 through app, website, or phone in all 50 states. First Stop Health prioritizes an engaging and easy-to-use experience, setting people on healthier journeys through care at multiple stages. We are proud to be recognized as one of Fast Company’s Most Innovative Companies.

First Stop Health offers a comprehensive benefits package that includes various health and medical coverage options, dental and vision coverage, disability and life coverage, making healthcare easily accessible. For those that choose to waive medical coverage a monthly medical waiver allowance will be provided.

First Stop Health offers a remote-first work environment and flexible paid time off, including Summer Fridays. Furthermore, the employer match 401k plan and monthly phone stipend demonstrates the company's commitment to employee financial well-being. The First Stop Health membership benefit is another added perk for employees and provides our virtual care solutions -- Urgent Care, Mental Health, and Primary Care -- from their very first day!

Job Description:

The Utilization Management (UM) Coordinator serves as a central administrative resource within the Utilization Management team, supporting members, providers, TPAs and internal clinical staff throughout the care journey. This cross-trained role performs a wide range of non-clinical functions across Utilization Management, Prior Authorization, Care Navigation, and Case Management activities.

The UM Coordinator acts as the first point of contact for many incoming requests, ensuring work is accurately received, prioritized, coordinated, and resolved whenever possible. The Coordinator facilitates communication between members, providers, and internal teams while supporting timely access to care, efficient authorization processing, and post-service coordination.

Although the role is non-clinical, the UM Coordinator plays an important role in identifying situations that require clinical review. When a member, provider, or case exceeds the established non-clinical scope, the Coordinator promptly escalates the request to a UM Nurse or leadership according to established clinical escalation guidelines.

Responsibilities:

Care Navigation & Member Support

• Serve as a primary point of contact for members seeking assistance with healthcare navigation.
• Assist members with locating in-network providers and participating facilities.
• Provide general education regarding health plan processes, benefits navigation, and available First Stop Health services within established guidelines.
• Route members to the appropriate internal department or external resource based on identified needs.
• Document all interactions accurately and thoroughly within designated systems.
• Identify situations requiring clinical intervention and immediately escalate to a UM Nurse or leadership.

Prior Authorization Coordination

• Receive, review, and process incoming prior authorization requests submitted via fax, portal, phone, or other approved channels.
• Ensure requests contain required demographic, administrative information and clinical information prior to clinical review.
• Serve as the primary administrative liaison with provider offices by obtaining required documentation, communicating case status, requesting additional information, and performing administrative outreach and follow-up as directed by the UM Nurse.
• Monitor authorization work queues to support timely turnaround times, proactively follow up on outstanding items, and escalate potential delays to the appropriate clinical team member as needed.
• Maintain accurate documentation throughout the authorization process.

Administrative Case Management Support

• Coordinate post-acute services for designated cases as assigned.
• Assist members undergoing outpatient orthopedic procedures (including total hip and total knee replacements) by coordinating durable medical equipment (DME), home health services, and other approved post-procedure needs.
• Perform follow-up outreach on cases delegated by UM Nurses.
• Track assigned cases to completion and communicate updates to the clinical team as appropriate.
• Promptly escalate any newly identified clinical concerns to the assigned UM Nurse in accordance with established clinical escalation protocols.

Provider & Internal Team Collaboration

• Serve as a liaison between providers, members, TPAs and internal First Stop Health departments.
• Coordinate administrative follow-up activities to facilitate timely care delivery.
• Respond to provider office inquiries in a professional, courteous, and service-oriented manner, resolving non-clinical issues whenever possible.
• Collaborate closely with UM Nurses to ensure smooth transitions when clinical review becomes necessary, per escalation protocol.
• Support department workflow by assisting across multiple functional areas based on operational priorities

Clinical Escalation & Operational Excellence

• Recognize situations that exceed the non-clinical scope of practice, within established clinical escalation protocols.
• Promptly communicate clinical concerns to a UM Nurse or leadership through established escalation pathways.
• Maintain confidentiality and comply with HIPAA and organizational policies.
• Participate in cross-training initiatives to support evolving departmental needs.
• Contribute to quality improvement efforts through accurate documentation, attention to detail, and continuous process improvement.
• Demonstrate exceptional customer service while supporting members and provider partners through every interaction.
• Perform other duties and special projects as assigned to support departmental and organizational objectives.

Requirements:

Education:

• High school diploma or equivalent required.
• Associate degree in healthcare administration, business, or a related field preferred.

Experience:

• Minimum of 2 years of experience in healthcare administration, utilization management support, care coordination, customer service, health insurance, medical office operations, or a related healthcare setting required.
• Experience working with prior authorization processes, provider office communication, managed care, or case coordination preferred.
• Experience using electronic medical records (EMRs), payer portals, and utilization management software preferred.

Skills:

• Exceptional customer service and communication skills.
• Strong organizational and time management abilities.
• Ability to prioritize multiple tasks in a fast-paced environment.
• Excellent verbal and written communication.
• Strong attention to detail and documentation accuracy.
• Ability to work collaboratively across interdisciplinary teams.
• Knowledge of medical terminology preferred.
• Understanding of health insurance, utilization management, and prior authorization workflows preferred.
• Proficiency in Microsoft Office Suite and healthcare information systems.
• Ability to recognize situations requiring clinical escalation and follow established escalation protocols.
• Demonstrated professionalism, discretion, and commitment to member-centered service.

First Stop Health is committed to diversity, equity, inclusion, and belonging. Research shows that women, people of color and other historically underrepresented groups tend to only apply to jobs in which they meet all the job requirements. Unsure if you check every box? Apply. We would love to consider your unique experiences and how you could make First Stop Health even better.

To learn more about First Stop Health, visit www.fshealth.com and if you require any assistance during the application process or have questions, please don't hesitate to contact our talent acquisition team via email at careers@fshealth.com