Utilization Management Specialist — Hybrid/Remote

Santa Barbara Cottage Hospital; United States; On-site; USD 46,000 - 73,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k match and retirement benefits

Paid Time Off (PTO)

Job summary

Blue Cross NC is hiring a Utilization Management Specialist to join the Government Pharmacy UM Operations Team. The role focuses on non-clinical reviews, communicating decisions to providers and members, and supporting department turnaround times in a hybrid/remote work model.

You will document review outcomes, perform outreach to obtain needed information, and refer cases requiring clinical input to a nurse or Medical Director.

Qualifications

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

Responsibilities

• Conducts nonclinical reviews based on applicable criteria and guidelines on requested services.
• Documents outcome of reviews and interprets non-clinical information.
• Completes outreach to providers or members to obtain the medical information for the review.
• 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 collection and notification standards.
• Assists administrative support with retrieval/attachment of facsimiles for processing.
• Serves as SME for CM&O around non-clinical review process.

Skills

Clinical Decision Making

Clinical Decision Support

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

Education

High school diploma or GED

Job description

Blue Cross NC is hiring a Utilization Management Specialist to join the Government Pharmacy UM Operations Team. The role focuses on non-clinical reviews, communicating decisions to providers and members, and supporting department turnaround times in a hybrid/remote work model.

You will document review outcomes, perform outreach to obtain needed information, and refer cases requiring clinical input to a nurse or Medical Director.