Healthcare Utilization Review Specialist
About The Position
Join our team at Company and build a meaningful career in employee benefits solutions. As a Healthcare Utilization Review Specialist, you’ll play a vital role in ensuring our clients and members receive the right care at the right time through customized, self-funded insurance programs. You’ll review claims for medical necessity, verify authorizations, and collaborate across clinical and administrative teams to support effective utilization management. This role is ideal for detail-oriented healthcare para-professionals who want to apply their knowledge of medical terminology and insurance processes in a supportive, team-driven environment.
Requirements
- Medical assistant, home health aide, nursing assistant, or other similar health care para-professional training or certification.
- Fluent computer skills including MS Office (Word, Excel, and Outlook) and Internet applications.
- Strong reading comprehension
- Self-motivated, self-directed, operates without constant guidance.
- Must be able to make sound logical decisions and articulate the reasoning.
Nice To Haves
- Prior training in coding, insurance, basic medical vocabulary, training or certification in these roles preferred but not required.
Responsibilities
- Review claims in utilization review queues for medical necessity and authorization status; determine appropriate processing based on coding and plan language.
- Support the daily operations of the Utilization Review department by assisting senior UR team members with case review activities.
- Conduct outreach calls and collect data using established scripts, tools, and protocols, while maintaining productivity and service standards.
- Process correspondence and faxes in accordance with timeliness standards; escalate to clinical team members when appropriate.
- Perform clerical and administrative tasks, including scanning, document retrieval, and urgent claims processing support.
- Communicate clearly, professionally, and courteously with internal and external stakeholders to resolve issues.
- Provide written direction to other team members (nurses, claims auditors) to support accurate claims processing.
- Maintain current knowledge of Standard Operating Procedures, member benefits, rights, and responsibilities.
- Ensure compliance with BCBS Association standards and company policies.
- Complete other related duties and projects as assigned.
Benefits
- Fantastic medical, dental, and vision insurance
- Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible!
- Company provided Basic Life and AD&D
- Company paid Short-Term and Long-Term Disability
- Flexible Spending Accounts
- 401(k) Retirement Plan with up to a 6% employer-match WOW! (100% fully vested after 3 years)
- 10+ paid holidays
- Generous paid vacation and sick time
- Annual Volunteer Paid Day
- Annual Tuition Reimbursement
- Annual Health and Wellness Reimbursement
- Lots of fun company events
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
