Clinical Documentation Integrity & Utilization Review Specialist at Abarca Health

Sioux Falls, South Dakota, United States

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$60,840 – $91,520Compensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

3-5 years working in healthcare or in a health system
Familiarity with medical terminology and healthcare documentation
Visual acuity adequate to perform position duties
Ability to communicate effectively with others, hear, understand, and distinguish speech and other sounds
Commitment to Avera’s mission, vision, core values, and social principles
Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE)
Maintain confidentiality
Work effectively in a team environment
Comply with safety principles, laws, regulations, and standards (e.g., CMS, The Joint Commission, DHHS, OSHA)

Responsibilities

Coordinates daily administrative tasks to facilitate collection, organization, and distribution of clinical documentation to support CDI/UR workflows
Provides Clinical Denial Management support: tracks, monitors, coordinates, and assists with routing of clinical denials to internal stakeholders as well as external payers/auditors
Serves as communication liaison for clinical teams related to exchange and issue resolution, and communicates non-clinical functions to payers to assist with compliance to payer policies
Assists as the primary liaison to management for identifying, documenting, and escalating workflow inefficiencies or opportunities for improvement
Proactively monitors operations to determine patterns or issues that require further collaboration to enhance overall program performance

Skills

Key technologies and capabilities for this role

Clinical Documentation IntegrityUtilization ReviewDenial ManagementAdministrative CoordinationWorkflow ManagementPayer CommunicationComplianceStakeholder LiaisonIssue ResolutionOperations Monitoring

Questions & Answers

Common questions about this position

What is the pay range for the Clinical Documentation Integrity & Utilization Review Specialist position?

The pay range is $29.25 - $44.00, with actual pay rate dependent upon experience.

Is this position remote or does it require working at a specific location?

This information is not specified in the job description.

What experience and skills are required for this role?

Candidates need 3-5 years working in healthcare or in a health system, along with familiarity with medical terminology and healthcare documentation. Strong organizational, communication, and coordination skills are essential for managing workflows and denial tracking.

What is the company culture like at Avera Health?

Avera Health emphasizes compassion, hospitality, and stewardship, with a commitment to its mission, vision, core values, and social principles to serve patients, families, and the community. Employees are part of a multidisciplinary team focused on Moving Health Forward.

What makes a strong candidate for this position?

A strong candidate has 3-5 years of healthcare experience, familiarity with medical terminology, and the ability to coordinate administrative tasks, manage clinical denials, and communicate effectively as a liaison. Preferred qualifications include an Associate's or Bachelor's degree.

Abarca Health

Pharmacy Benefit Management services provider

About Abarca Health

Abarca Health provides Pharmacy Benefit Management (PBM) services, focusing on flexible and user-friendly solutions for health plans, employers, and government programs like Medicare and Medicaid. Its main product, the Darwin platform, allows clients to quickly implement and modify benefit designs while ensuring compliance with regulations. Abarca Health manages over $5.3 billion in drug spend and processes 100 million prescription claims annually, offering additional services like home delivery for prescriptions. The company's goal is to deliver exceptional service and innovative solutions in the PBM market.

Aventura, FloridaHeadquarters

2005Year Founded

VENTURE_UNKNOWNCompany Stage

HealthcareIndustries

501-1,000Employees

Benefits

PTO

Parental leave

Work flexibility

Health insurance

Wellness stipend

401k

Tuition reimbursement

Leadership development programs

Risks

Increased competition from Amazon Pharmacy and Mark Cuban's Cost Plus Drug Company.

Growing focus on specialty drugs may require platform adaptation.

Shift towards price transparency could pressure Abarca's pricing models.

Differentiation

Abarca Health's Darwin platform is highly adaptable and user-friendly.

The company offers innovative programs like Triple S en Casa for home delivery.

Abarca Health ensures compliance with ever-changing healthcare regulations.

Upsides

Abarca transitioned two million members to Darwin in 18 months, showing operational efficiency.

Collaboration with Blue Shield of California boosts Abarca's reputation in the PBM sector.

Recognition as a top IT workplace attracts top talent, driving innovation.

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