Utilization Management Specialist — Hybrid/Remote Flex

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

Benefits offered by this job

Health benefits

401k match

Paid Time Off

Parental leave

Job summary

Habitat For Humanity Of Durham is seeking a Utilization Management Specialist to join our Commercial Pharmacy Phone & UMS Team. You will perform non-clinical reviews and communicate decisions to providers and members to support utilization management activities.

The role emphasizes accurate documentation, outreach to obtain needed information, and collaboration with nurses or Medical Directors when clinical review is required.

Qualifications

• High school diploma or GED is required.
• 3+ years of experience in a related field.
• Experience in health care/utilization management is a plus.

Responsibilities

• Conducts nonclinical reviews based on criteria and guidelines and communicates decisions to providers/members.
• Documents review outcomes and interprets non-clinical information.
• Completes outreach to providers/members to obtain medical information for reviews.
• Identifies cases requiring clinical review and refers them to a nurse or Medical Director.
• Reviews authorizations to ensure accuracy and protect claims payments.
• Supports CMS = Centers for Medicare & Medicaid Services requirements through outreach.
• Aids the admin team by retrieving and attaching facsimiles for processing.
• Serves as a subject matter expert for CM&O in non-clinical review processes.

Skills

Non-clinical reviews

Documentation

CMS knowledge

Outreach

Communication

Education

High school diploma or GED

Job description

Habitat For Humanity Of Durham is seeking a Utilization Management Specialist to join our Commercial Pharmacy Phone & UMS Team. You will perform non-clinical reviews and communicate decisions to providers and members to support utilization management activities.

The role emphasizes accurate documentation, outreach to obtain needed information, and collaboration with nurses or Medical Directors when clinical review is required.