Hybrid/Remote Utilization Management Specialist

Blue Cross NC; United States; Hybrid; USD 46,000 - 73,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k match

Paid Time Off

Parental leave and adoption support

Job summary

Blue Cross NC is seeking a Utilization Management Specialist to join the Government Pharmacy UM Operations Team. The role focuses on completing non-clinical reviews and communicating decisions to providers and members to support utilization management activities.

In addition to reviews, you’ll support admin functions, assist CMS information requests, and coordinate with care management to help ensure timely processing and accurate claims.

Qualifications

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

Responsibilities

• Conduct nonclinical reviews based on criteria and guidelines and communicate decisions to providers or members.
• Document outcomes of reviews and interpret non-clinical information.
• Outreach to providers or members to obtain information for reviews.
• Refer determinations needing clinical review to a nurse or Medical Director.
• Review authorizations to ensure accuracy and protect claims payments.
• Support CMS information gathering and notification standards.
• Assist admin teams with retrieval/attachment of facsimiles for processing.
• Serve as SME for CM&O on the non-clinical review process.

Skills

Non-clinical reviews

Communication

Utilization Management

CMS requirements

Education

High school diploma or GED

Job description

Blue Cross NC is seeking a Utilization Management Specialist to join the Government Pharmacy UM Operations Team. The role focuses on completing non-clinical reviews and communicating decisions to providers and members to support utilization management activities.

In addition to reviews, you’ll support admin functions, assist CMS information requests, and coordinate with care management to help ensure timely processing and accurate claims.