Utilization Management Specialist

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

📋 Description

• Perform nonclinical evaluations based on relevant criteria and guidelines for services requested.

• Relay review decisions to providers and/or members in accordance with departmental protocols.

• Record review results and interpret as well as analyze non-clinical data.

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

• Identify and forward any determinations that need clinical review to a nurse or Medical Director.

• Verify authorizations for precision to mitigate impacts on claims payments.

• Aid in care management by engaging with members and providers to comply with CMS information solicitation and notification requirements.

• Retrieve and append facsimiles to facilitate customer requests for processing.

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

⛳️ Requirements

• Possession of a high school diploma or GED.

• Over 3 years of experience in a relevant field.

• Experience in a call center environment is advantageous.

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

• Capability to conduct nonclinical evaluations based on applicable criteria and guidelines.

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

• Ability to document and analyze non-clinical review data.

• Skill in performing verbal or nonverbal outreach to providers or members.

• Competence to identify and refer organizational determinations that require clinical review.

• Familiarity with utilization management, healthcare policies, healthcare regulations, medical billing and coding, and medical information.

🏝️ Benefits

• Attainable work-life balance, flexibility, and autonomy.

• Comprehensive medical, dental, and vision coverage.

• Programs promoting health and wellness.

• Parental leave and supportive measures.

• Assistance with adoption and surrogacy.

• Opportunities for career development.

• Tuition reimbursement for ongoing education.

• 401k matching, including an annual company contribution.

• Annual Incentive Bonus.

• Paid Time Off (PTO).