Utilization Management Specialist

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Perform nonclinical assessments of requested services in accordance with relevant criteria and guidelines.

• Relay review determinations to providers and/or members following departmental protocols.

• Record review results and analyze non-clinical information.

• Reach out to providers or members to gather medical information necessary for reviews.

• Recognize and refer organizational decisions needing clinical review to a nurse or Medical Director.

• Validate authorizations for accuracy to prevent impacts on claims payments.

• Engage with members or providers to ensure compliance with CMS information solicitation and notification standards.

• Retrieve and attach faxes and direct customer requests to the correct processing area.

• Act as a subject matter expert for CM&O in the non-clinical review process.

• Provide administrative assistance to ensure departmental turnaround times are met.

⛳️ Requirements

• High school diploma or GED is required.

• Over 3 years of experience in a related field.

• Experience in a call center environment is advantageous.

• Customer service experience within the healthcare/medical sector is a plus.

• Capability to perform nonclinical reviews based on relevant criteria and guidelines.

• Proficient in communicating decisions to providers and/or members according to departmental protocols.

• Skilled in documenting, interpreting, and analyzing non-clinical information.

• Ability to conduct outreach, either verbal or nonverbal, to providers or members.

• Competence in identifying and referring organizational decisions that require clinical review.

• Ability to review authorizations for precision.

• Proficient in retrieving and attaching faxes.

🏝️ Benefits

• Work-life balance, flexibility, and autonomy.

• Coverage for medical, dental, and vision needs.

• Participation in health and wellness programs.

• Parental leave and associated support.

• Assistance with adoption and surrogacy.

• Opportunities for career development.

• Tuition reimbursement for ongoing education.

• 401(k) matching, including an annual company contribution.

• Annual Incentive Bonus.

• Paid Time Off (PTO).