Utilization Management Specialist

Habitat For Humanity Of Durham; United States; Hybrid; USD 46,000 - 73,000; Full time

Benefits offered by this job

401k match

PTO

Health benefits

Tuition reimbursement

Parental leave

Job summary

Habitat For Humanity Of Durham is seeking an Utilization Management Specialist to support the Government Pharmacy UM Operations Team with non-clinical reviews and outreach to providers/members. The role emphasizes accuracy, CMS compliance, and timely communications in a hybrid-flex work setting.

The position requires a high school diploma or GED and 3+ years in a related field; call center or healthcare/medical customer service experience is a plus.

Qualifications

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

Responsibilities

• Conducts nonclinical reviews based on applicable criteria and guidelines and communicates decisions to providers/members per protocols.
• Documents outcomes of reviews and interprets non-clinical information.
• Performs 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 solicitation standards and retrieval of facsimiles for processing.
• Serves as SME for CM&O regarding non-clinical review process.

Education

High school diploma or GED

Job description

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.

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

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