Utilization Management Specialist

Motion Recruitment; Durham (NC); Remote; USD 65,000 - 80,000; Full time

Job summary

Motion Recruitment is seeking a Utilization Management Specialist for a remote contract role serving health insurance clients. The candidate will perform non-clinical reviews, communicate determinations to providers and members, and document outcomes while interpreting non-clinical information.

Eligible applicants must pass drug and background checks. Reqs include 3–5 years in related field with UM experience, high-volume workflow, and strong attention to detail.

Qualifications

• 3–5 years of experience in a related field.
• UM experience and high-volume review skills.
• High school diploma or GED required.

Responsibilities

• Conducts non clinical 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 non verbal 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 CMS requirements.
• 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.

Skills

UM experience

Attention to detail

High volume environment

Education

High school diploma or GED

Job description

Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Utilization Management Specialist. They have over 4 million customers and 5,000+ employees dedicated toproviding innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.

Location

While the position is Remote, work from home, you must reside in North Carolina or one of the following states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

Required Skills

• High school diploma or GED
• 3-5 years of experience in related field
• High volume experience, UM experience, strong attention to detail

Preferred Skills

• Retail Pharm Tech, Medicare Exp

What you will be doing

• Conducts non clinical 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 non verbal 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.

To be eligible to contract at this client you must be able to pass a drug test and criminal background check.