Utilization Management Specialist

🔥 12 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $45.8k - $73.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Blue Cross NC

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross NC is a health insurance provider that offers a range of health plans and services to individuals and groups. The company focuses on delivering quality healthcare coverage and improving health outcomes for its members through innovative health programs and services. Blue Cross NC is committed to enhancing access to affordable healthcare while supporting the health and wellness of the communities it serves.

📋 Description

• Conduct nonclinical reviews based on applicable criteria and guidelines for requested services • Communicate review decisions to providers and/or members according to department protocols • Document review outcomes and interpret and analyze non-clinical information • Conduct outreach to providers or members to obtain medical information • Identify and refer determinations requiring clinical review to a nurse or Medical Director • Review authorizations for accuracy to avoid impacts on claims payment • Support care management through member and provider outreach to meet CMS information solicitation and notification standards • Retrieve and attach facsimiles to forward customer requests for processing • Serve as a subject matter expert on the non-clinical review process for CM&O

🎯 Requirements

• High school diploma or GED • 3+ years of experience in related field • Call center experience is a plus • Customer service experience in the healthcare/medical space is a plus • Ability to conduct nonclinical reviews based on applicable criteria and guidelines • Ability to communicate decisions to providers and/or members according to department protocols • Ability to document and analyze non-clinical review information • Ability to conduct verbal or nonverbal outreach to providers or members • Ability to identify and refer organization determinations requiring clinical review • Knowledge of utilization management, healthcare policies, health care regulation, medical billing and coding, and medical information

🏖️ Benefits

• Work-life balance, flexibility, and autonomy • Medical, dental, and vision coverage • Health and wellness programs • Parental leave and support • Adoption and surrogacy assistance • Career development programs • Tuition reimbursement for continued education • 401k match including an annual company contribution • Annual Incentive Bonus • Paid Time Off (PTO)