Utilization Management Specialist - Hybrid/Remote

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

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401k match

Paid time off

Annual bonus

Job summary

Blue Cross NC is seeking a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS Team. This role focuses on non-clinical reviews and communication to members and providers to support utilization management activities.

Responsibilities include documenting outcomes, obtaining information for reviews, and escalating clinical reviews when needed. Hybrid Flex work arrangement available with remote and in-person collaboration.

Qualifications

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

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.
• Performs outreach 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 payment.
• Supports CMS information solicitation requirements through outreaches.
• Assists the administrative support team with fax retrieval and attachment for processing.
• Acts as a subject matter expert for CM&O around non-clinical review processes.

Skills

Experience in related field

Education

High school diploma or GED

Job description

Blue Cross NC is seeking a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS Team. This role focuses on non-clinical reviews and communication to members and providers to support utilization management activities.

Responsibilities include documenting outcomes, obtaining information for reviews, and escalating clinical reviews when needed. Hybrid Flex work arrangement available with remote and in-person collaboration.