Utilization Management Specialist

Blue Cross and Blue Shield of North Carolina • Remote Flex - North Carolina, NC

1d • $45,761 - $73,217 • Hybrid

About The Position

We’re hiring a Utilization Management Specialist to join the Government Pharmacy UM 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.

Requirements

• High school diploma or GED
• 3+ years of experience in related field.

Nice To Haves

• Call center experience is a plus.
• Customer service experience in the healthcare/medical space is a plus.

Responsibilities

• Conducts nonclinical reviews based on applicable criteria and guidelines on requested services.
• Communicates decision to provider and/or member, according to department protocols.
• Documents outcome of reviews and demonstrates the ability to interpret and analyze the non-clinical information.
• Completes verbal or nonverbal outreach to providers or members to obtain the medical information for the review.
• Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director.
• Conducts reviews of authorizations entered to ensure accuracy to avoid impacting claims payment.
• Supports 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.
• Supports the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing.
• Serves as a subject matter expert for CM&O around the non-clinical review process.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED