Utilization Management Specialist

Blue Cross and Blue Shield of North Carolina; North Carolina; Hybrid; USD 46,000 - 73,000; Full time

Benefits offered by this job

Health, Dental, Vision

401(k) match

PTO and wellness programs

Career development and tuition support

Job summary

Blue Cross and Blue Shield of North Carolina is hiring a Utilization Management Specialist to support non-clinical reviews and communications with providers and members. The role participates in CMS-required outreach, ensures accurate review documentation, and supports administrative tasks within a hybrid-flex work model.

Qualifications include a high school diploma or GED and 3+ years in a related field. Call center and healthcare customer service experience are a plus.

Qualifications

• 3+ years of experience in related field.
• Non-clinical reviews based on applicable criteria and guidelines.

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 interprets non-clinical information.
• Completes outreach to providers or members to obtain medical information for reviews.
• Identifies and refers determinations needing clinical review to a nurse or Medical Director.
• Reviews authorizations to ensure accuracy to avoid impacting claims payment.
• Supports CMS information gathering and notification requirements.
• Assists with retrieval and attachment of facsimiles for processing.

Skills

Clinical Decision Making

Clinical Decision Support

Clinical Documentation Review

Clinical Information Systems

Clinical Review

Patient Care

Patient Care Coordination

Utilization Management

Education

High school diploma or GED

Job description

Job Description We’re hiring a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS 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.

What You’ll Do

• 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.

What You Bring

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

Bonus Points (Preferred qualifications)

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

What You’ll Get

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• 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

Learn more https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC

Where You’ll Work

Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in‑person connection – that supports a workplace that’s flexible, connected, and future focused. In a Hybrid‑Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in‑office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance. $45,761.00 - $73,217.00

Skills

Clinical Decision Making, Clinical Decision Support (CDS), Clinical Documentation Review, Clinical Information Systems, Clinical Review, Healthcare Policies, Health Care Regulation, Medical Billing and Coding, Medical Care, Medical Information, Medical Review, Patient Advocacy, Patient Care, Patient Care Coordination, Utilization Management

Authorization to Work in the United States

We use E‑verify to confirm authorization to work in the United States. To learn more about E‑Verify, including your rights and responsibilities, please visit E‑Verify Overview for English or Visión General de E‑Verify for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application, hiring process, or have technical issues that prevent you from completing your application please notify HR at [e-mail]. Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming