Utilization Management Specialist
About The Position
We’re seeking Utilization Management Specialists to join the Government Pharmacy Utilization Management Operations Team! The Utilization Management Specialist is responsible for the completion of non-clinical reviews and communication to customers to support utilization management reviews and activities. The Utilization Management Specialist may also provide support for administrative functions within the department to support turnaround times. Shift schedule: 8 AM – 5 PM EST, and includes rotating to cover weekend and holiday shifts
Requirements
- High school diploma or GED
- 3+ years of experience in a related field
Nice To Haves
- Previous Utilization Management, pharmacy experience strongly preferred
- Strong customer service and communication skills
Responsibilities
- 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.
Benefits
- 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
- Based on annual corporate goal achievement and individual performance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
