Healthcare Utilization Review Specialist

This is a fully remote position, open to applicants in New Hampshire, +1 more state.

📋 Description

• Prepare and coordinate the review of group renewal information as required during each group's renewal period and upon special request.

• Evaluate claims submitted to UR Queues for medical necessity and check authorizations for on-file and not-on-file statuses.

• Make decisions on claims processing based on coding evaluations.

• Analyze medical data and oversee utilization review processes.

• Work in partnership with clinical and administrative teams to enhance effective utilization management.

• Assist the Senior Utilization Review Specialist to support the daily operations of the Utilization Review department.

• Keep updated knowledge of UR processes and timelines.

• Conduct outreach calls, gather data following scripts, tools, and protocols, and refer information to the appropriate staff as indicated by workflow.

• Manage incoming and outgoing correspondence and faxes in accordance with standards and timely guidelines.

• Execute urgent scanning and document retrieval for claims directed to UR.

• Interpret plan language and apply it to specialist tasks.

• Process claims in compliance with BCBS Association standards.

⛳️ Requirements

• A minimum of one (1) year of experience in a healthcare payer, third-party administrator (TPA), utilization management/utilization review, health insurance, claims administration, or a similar healthcare setting.

• Experience in reviewing healthcare claims, authorizations, referrals, or medical documentation while applying established review criteria.

• Capability to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to facilitate claims and utilization review decisions.

• Familiarity with medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems.

• Strong analytical and critical-thinking abilities to make precise, well-reasoned determinations based on the documentation available.

• Proficient in Microsoft Office applications, including Word, Excel, and Outlook, with the capacity to quickly learn new systems and technologies.

• Exceptional written and verbal communication skills, with the ability to engage professionally with providers, members, and internal stakeholders.

• Experience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions.

• Knowledge of BCBS Association guidelines, utilization management workflows, or health plan operations.

• Familiarity with Javelina or other healthcare claims and case management systems.

• Background as a Medical Assistant, Nursing Assistant, Home Health Aide, or similar healthcare paraprofessional training, or related clinical experience.

• Possession of CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health benefits package including medical, dental, and vision coverage.

• Opportunities for professional development and continuous learning.

• Flexible working hours and remote work options.

• Supportive work environment with a focus on teamwork and collaboration.