Utilization Management Specialist — Hybrid/Remote Flex

NC Health Affiliates; United States; Hybrid; USD 46,000 - 73,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Parental leave

Tuition reimbursement

401k match

PTO

Wellness programs

Job summary

Blue Cross NC is hiring a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS Team. The role focuses on completing non-clinical reviews and communicating decisions to providers and members, supporting utilization management activities.

You will work in a Hybrid-Flex environment with remote options; in-office two days weekly. Benefits include medical, dental, vision, parental leave, tuition reimbursement, a 401(k) match, and PTO, with a commitment to community health and

Qualifications

• High school diploma or GED.
• 3+ years of experience in related field.
• Call center or healthcare customer service experience preferred.

Responsibilities

• Conduct nonclinical reviews based on criteria and guidelines and communicate decisions.
• Document outcomes and interpret nonclinical information.
• Outreach to providers or members to obtain medical information for reviews.
• Refer determinations needing clinical review to a nurse or Medical Director.
• Review authorizations for accuracy to avoid impacting claims.
• Support CMS information solicitation requirements.
• Serve as CM&O subject matter expert on nonclinical review.

Skills

Attention to detail

Non-clinical review experience

Communication with providers

Customer service

CMS compliance awareness

Education

High school diploma or GED

Job description

Blue Cross NC is hiring a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS Team. The role focuses on completing non-clinical reviews and communicating decisions to providers and members, supporting utilization management activities.

You will work in a Hybrid-Flex environment with remote options; in-office two days weekly. Benefits include medical, dental, vision, parental leave, tuition reimbursement, a 401(k) match, and PTO, with a commitment to community health and