Utilization Review Specialist

TEKsystems

4d • $35 - $50 • Hybrid

About The Position

The Retro Claims Reviewer is responsible for auditing and reviewing medical claims to ensure accuracy, regulatory compliance, and proper adjudication. This role is ideal for a Licensed Vocational Nurse (LVN) or Registered Nurse (RN) with hands-on experience in Utilization Management (UM) and a strong understanding of HMO/Medicare claims processes.

Requirements

• Active LVN or RN license (California)
• 2+ years of experience in Utilization Management (UM)
• Hands-on experience with HMO/Medicare claims, audits, and denials
• Familiarity with claims processing systems (EZCap or similar)
• Strong analytical, documentation, and communication skills
• Ability to work independently and prioritize tasks
• Proficiency in MS Office Suite (Excel, Access, PowerPoint, Word)

Nice To Haves

• CPT, HCPCS, ICD-10 coding knowledge
• Advanced Excel skills
• Experience with regulatory agencies and compliance audits

Responsibilities

• Audit denied provider and member claims for accuracy and compliance
• Review and process claims in accordance with UM guidelines and regulatory standards
• Analyze benefit structures and system configurations (EZCap or similar)
• Collaborate with cross-functional teams to resolve claim issues and process gaps
• Document findings, prepare reports, and present trends to leadership
• Support automated adjudication systems and identify strategies to reduce errors
• Ensure HIPAA and PHI compliance throughout all claim review activities
• Participate in special projects related to claim denials and appeals

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees