Utilization Management Specialist

Job Description

**Shift schedule: 8 AM - 5 PM EST, and includes rotating to cover weekend and holiday shifts**

What You'll Do

• Conduct non clinical reviews based on applicable criteria and guidelines on requested services. Communicate decision to provider and/or member, according to department protocols.

• Document outcome of reviews and demonstrate the ability to interpret and analyze the non-clinical information.

• Complete verbal or non verbal outreach to providers or members to obtain the medical information for the review.

• Identify and refer organization determinations that require a clinical review to a nurse or Medical Director.

• Conduct reviews of authorizations entered to ensure accuracy to avoid impacting claims payment.

• Support the care management department by completing outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards.

• Support the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing.

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

What You Bring

• High school diploma or GED

• 3+ years of experience in a related field

Bonus Points (preferred qualifications)

• Previous Utilization Management, pharmacy experience strongly preferred

• Strong customer service and communication skills

What You'll Get

The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community

• Work-life balance, flexibility, and the autonomy to do great work

• Medical, dental, and vision coverage along with numerous health and wellness programs

• Parental leave and support plus adoption and surrogacy assistance

• Career development programs and tuition reimbursement for continued education

• 401k match including an annual company contribution

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

Skills