Utilization Management Specialist # 26-26425
About The Position
Under the direction of the Precertification Team Manager, the Utilization Management Specialist manages daily non-clinical review activities supporting the clinical, business, and operational functions of the Utilization Management department. The specialist coordinates coverage determinations for designated products and accounts, prepares and edits medical necessity denial letters, and monitors daily processes performed by coordinators. The role works closely with internal departments, healthcare providers, hospitals, and provider office staff to support quality, accuracy, compliance, and timely issue resolution. This is a six-month remote position based in Canton, Massachusetts. Candidates located in New England states—including Massachusetts, Rhode Island, Connecticut, New Hampshire, Maine, and Vermont—are preferred.
Requirements
- Bachelor’s degree or equivalent relevant work experience.
- At least 3 years of experience in a managed care or healthcare industry environment.
- Excellent written and verbal communication skills.
- Proficiency and accuracy in data entry across multiple applications.
- Ability to identify urgent situations and follow established protocols.
- Strong organizational, analytical, problem-solving, and conflict-resolution skills.
- Ability to manage multiple priorities in a complex and sensitive work environment.
- Strong attention to detail and commitment to quality and accuracy.
- Self-motivated, proactive, and capable of working independently.
- Excellent interpersonal and customer service skills.
- Ability to collaborate effectively with healthcare providers, hospitals, and internal stakeholders.
Nice To Haves
- Candidates located in New England states such as Massachusetts, Rhode Island, Connecticut, New Hampshire, Maine, or Vermont are preferred.
Responsibilities
- Write and edit medical necessity denial letters.
- Participate in structured training programs for new staff.
- Assist in training existing employees on new procedures, processes, and systems.
- Conduct staff audits and support monitoring activities to ensure the quality and accuracy of coordinators’ work.
- Coordinate coverage determinations for designated products and accounts.
- Assist partner departments in resolving claims discrepancies and misdirected activities.
- Investigate root causes of operational issues and recommend appropriate solutions.
- Support departmental administrative activities, information requests, and follow-ups.
- Participate in projects and special assignments to meet departmental deadlines and compliance requirements.
- Represent the department on committees as requested.
- Communicate regularly with network providers, hospital contacts, provider office staff, and internal departments.
- Perform other duties and responsibilities as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
