Utilization Management Specialist
About The Position
The Utilization Management Specialist joins the Commercial Pharmacy Phone & UMS Team and completes non-clinical reviews and customer communications supporting utilization management reviews and activities. The role may also provide administrative support to help meet turnaround times. The specialist conducts reviews using applicable criteria and guidelines, documents and analyzes review outcomes, and communicates decisions to providers and/or members according to department protocols. The position also supports care management and administrative processes, including outreach, authorization accuracy reviews, and retrieval and routing of facsimiles. The specialist serves as a subject matter expert for CM&O on the non-clinical review process.
Requirements
- High school diploma or GED.
- At least 3 years of experience in a related field.
Nice To Haves
- Call center experience.
- Customer service experience in the healthcare or medical space.
Responsibilities
- Conduct nonclinical reviews of requested services based on applicable criteria and guidelines, and communicate decisions to providers and/or members according to department protocols.
- Document review outcomes and interpret and analyze non-clinical information.
- Contact providers or members verbally or nonverbally to obtain medical information for reviews.
- Identify organization determinations requiring clinical review and refer them to a nurse or Medical Director.
- Review entered authorizations for accuracy to help avoid impacts to claims payment.
- Complete outreach to members or providers to support care management and meet CMS information-solicitation or notification standards.
- Retrieve and attach facsimiles and forward customer requests to the appropriate area for processing.
- Serve as a subject matter expert for CM&O on the non-clinical review process.
- Provide administrative support within the department as needed to support turnaround times.
Benefits
- Medical, dental, and vision coverage.
- Health and wellness programs.
- Parental leave and support.
- Adoption and surrogacy assistance.
- Career development programs.
- Tuition reimbursement for continued education.
- 401(k) match, including an annual company contribution.
- Annual incentive bonus.
- Paid time off (PTO).
- Work-life balance, flexibility, and autonomy.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
