Utilization Management Specialist

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

Benefits offered by this job

Hybrid work model

Health, dental, and vision coverage

Parental leave and adoption support

Tuition reimbursement

Job summary

Blue Cross and Blue Shield of North Carolina is seeking a Utilization Management Specialist to join the Government Pharmacy UM Operations Team in a Hybrid role in North Carolina, United States.

The position involves completing non-clinical reviews, communicating decisions to providers or members, and supporting administrative functions to maintain turnaround times. A high school diploma or GED and 3+ years in related field are required.

Qualifications

• High school diploma or GED.
• 3+ years of experience in related field.
• Bonus points for call center experience.
• Healthcare/medical customer service experience is a plus.

Responsibilities

• Conducts nonclinical reviews based on applicable criteria and guidelines for requested services.
• Communicates review decisions to providers and/or members per department protocols.
• Documents outcomes of reviews and interprets non-clinical information.
• Outreaches to providers or members to obtain medical information for review.
• Identifies and refers determinations needing clinical review to a nurse or Medical Director.
• Reviews authorizations to ensure accuracy to avoid impacting claims.
• Supports CMS information solicitation requirements for care management.
• Assists admin team with retrieval/attachment of faxes for processing.
• Serves as CM&O SME for non-clinical review process.

Skills

Customer service

Call center experience

Healthcare knowledge

Education

High school diploma or GED

Job description

Blue Cross and Blue Shield of North Carolina

Hybrid - North Carolina, United States

Sep 16, 2026

$45,761 - $73,217/year

Job Description

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.

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.

WhatYou’llGet

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

Our Hybrid Flex approach is builton presencewith a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplacethat'sflexible, connected, and future focused.

In a Hybrid-Flex role,you'llwork in the office at least two days a week for collaboration and connection. In a Remote Flex role,you'llwork 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

_____________________________________________________________________

Blue Cross and Blue Shield of North Carolina

Improving the health and well-being of our customers & communities - we won't stop until health care is better for all

Blue Cross NC is a not-for-profit health insurance provider dedicated to improving the health and well-being of over 4.3 million members in North Carolina.

4613 University Drive, Durham, NC 27707, US

Company Blue Cross and Blue Shield of North Carolina

Location Hybrid - North Carolina, United States