Healthcare Utilization Review Specialist

Socket.dev; Austin (TX); Hybrid; USD 60,000 - 75,000; Full time

Job summary

Socket.dev is seeking a Utilization Review Specialist in Exeter, NH or remote options to support our healthcare operations. You will prepare and coordinate group renewal reviews, assess medical necessity of claims, and apply coding rules under supervision.

You will collaborate with clinical and administrative teams, maintain UR process knowledge, and handle outreach calls and data collection per scripts and protocols, ensuring timely, accurate review decisions for members and providers.

Qualifications

• One or more years in healthcare payer or utilization review.
• Experience reviewing healthcare claims and applying review criteria.
• Ability to interpret health plan language and coding basics.

Responsibilities

• Supports UR department operations with various tasks.
• Maintains knowledge of UR processes and timelines.
• Conducts calls and data collection per scripts and protocols.
• Refer to clinical staff for review as defined by workflow.
• Adheres to SOPs and member benefits information.
• Processes claims within BCBS standards.

Skills

Healthcare payer

Claims review

Medical terminology

Analytical thinking

Communication skills

Microsoft Office

Tools

Microsoft Word

Excel

Outlook

Job description

Description

Location: Exeter, NH/ South Burlington, VT/ Hybrid/ Remote

Employment Status: Full-time

FLSA Status: Non-Exempt

Reports To: Utilization Review Process Manager

Job Summary:

Under the supervision of the Utilization Review Process Manager, the Utilization Review Specialist will use professional discretion and judgment to prepare and coordinate reviews of group renewal information as needed at each group’s renewal time, as well as upon special request. You will review claims submitted to UR Queues for medical necessity, for on file/not on file authorizations. Make determinations for claims processing based upon coding. This position involves interpretation of medical data, coordination of review processes, and collaboration with clinical and administrative teams to support effective utilization management.

Key Responsibilities:

• Supports the daily operations of the Utilization Review department by assisting the Senior Utilization Review Specialist with various tasks.
• Maintains a current knowledge base of UR processes and timelines.
• Uses good listening skills, conducts outreach calls, collects data according to script, tools, and protocols meeting both productivity and performance expectations as identified by manager. Conducts all calls in a courteous and customer service friendly manner. Refers to appropriate staff when indicated by workflow.
• Processes incoming and outgoing correspondence/faxes as assigned in accordance with required standards and within respective timeliness guidelines. Referring to the appropriate clinical team members for review as defined by workflow, when relating to claims or TOC outreach.
• Clerical responsibilities such as processing urgent scanning, and document retrieval when relating to claims routed to UR.
• Demonstrates a professional and courteous manner when communicating with others with the ability to state clearly and accurately the agreed upon resolution.
• Adhere to Standard Operating Procedures and maintains current knowledge of member benefits, rights and responsibilities.
• Performs other related duties and projects as assigned within the assigned timeframes.
• Interprets Plan language and applies to specialist tasks.
• Adheres to company policies and procedures.
• Processes claims, within BCBS association standards, a knowledge of these standards required.

Requirements

Required Qualifications

• One (1) or more years of experience in a healthcare payer, third-party administrator (TPA), utilization management/utilization review, health insurance, claims administration, or related healthcare environment.
• Experience reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteria.
• Ability to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to support claims and utilization review decisions.
• Working knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems.
• Strong analytical and critical-thinking skills with the ability to make accurate, well-reasoned determinations based on available documentation.
• Proficiency with Microsoft Office applications, including Word, Excel, and Outlook, and the ability to learn new systems and technology quickly.
• Excellent written and verbal communication skills and the ability to interact professionally with providers, members, and internal stakeholders.

Preferred Qualifications

• Experience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions.
• Experience with BCBS Association guidelines, utilization management workflows, or health plan operations.
• Experience using Javelina or other healthcare claims and case management systems.
• Medical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical background.
• CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.