Utilization Management Scheduler

Join the Vital Core Team in Massachusetts! We’re people who are fueled by passion, not by profit.

Vital Core Health Strategies (VCHS), an industry leader in Correctional Healthcare, has an opening for a Part‑time (16 hours per week) Utilization Management Scheduler at the Regional Office in Hopkinton, MA.

Looking for a rewarding career in the field of healthcare? At Vital Core we pride ourselves on retaining and acquiring hardworking ethical individuals who are committed to providing quality services. Join our team and experience first‑hand how Vital Core Health Strategies promotes a positive work environment that is based on respect and appreciation of the hard work and dedication of our staff.

Holiday Pay:
New Year’s Day, Martin Luther King Jr. Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Veteran’s Day, Thanksgiving Day, and Christmas Day. Medical, Dental, Vision. Health Savings Account;
Dependent Care Flexible Spending Account;
Life Insurance;
Short Term/Long Term Disability;
Identity Theft Protection;
Pet Insurance;
Employee Assistance Program and Discount Center; 401(k) & Plan Matching; PTO.

The Utilization Management Scheduler is responsible for case management for patients to advocate for optimum healthcare.

• Responsible for accurate flow of medical information between patients, outside providers, and third‑party payers.
• Researches and analyzes data for accuracy required for reimbursement.
• Analyzes medical billing and identifies documentation deficiencies.
• Uses established criteria to conduct preliminary decision review for services requiring prior authorization.
• Assesses the need for additional information to complete a service decision request.
• Works closely with UM team to escalated decisions that require clinical review and oversight.
• Communicates results of reviews in UM program for the primary care team and clinical reviewers.
• Handles all requests for review of authorization and data accuracy timely and efficiently.
• Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual, and compliance requirements.
• Maintains proficiency with technology such as Microsoft, Excel, and other platforms as required.
• Maintains great customer service skills, including interpersonal conversation, patience, and empathy.
• Problem‑solves and uses critical thinking skills.
• Maintains knowledge of CPT and ICD coding, as required. Provides flexibility and understanding of individualized care plans.
• Works efficiently independently to make decisions and in a team, as needed.
• Maintains security of patient information / adheres to HIPAA requirements.
• Other duties as assigned.

• Associate’s degree or equivalent experience – Bachelor’s degree preferred.
• Has an active certification in Medical Coding.
• 10+ years professional work experience in healthcare, managed care, or insurance preferred.
• Education, training, or experience as a medical coder, medical billing, or insurance coordinator required.
• Must be fluent in English language, including reading, writing, speaking, and understanding.
• Must be a supportive team member who contributes to and demonstrates teamwork and team concept.
• Able to make independent decisions when circumstances warrant such action.
• Able to deal tactfully with personnel, family members, visitors, government agencies/personnel, and the general public.

Vital Core Health Strategies is an equal opportunity employer and is committed to creating and maintaining an inclusive workplace in which all employees have an opportunity to participate and contribute to the success of the business and are valued for their skills, experience, and unique perspectives.