Utilization Management Specialist

🔥 13 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 of requested services based on applicable criteria and guidelines • Communicate review decisions to providers and/or members according to department protocols • Document review outcomes and interpret and analyze non-clinical information • Contact providers or members to obtain medical information for reviews • Identify and refer organization determinations requiring clinical review to a nurse or Medical Director • Review authorizations for accuracy to help avoid claims payment impacts • Complete outreach to members or providers to support CMS information solicitation and notification standards • Retrieve and attach facsimiles and forward customer requests to the appropriate processing area • Serve as a subject matter expert for CM&O on the non-clinical review process • Provide administrative support to help meet departmental turnaround times

🎯 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, interpret, and analyze non-clinical information • Ability to conduct verbal or nonverbal outreach to providers or members • Ability to identify and refer organization determinations requiring clinical review • Ability to review authorizations for accuracy • Ability to retrieve and attach facsimiles

🏖️ 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 • 401(k) match including an annual company contribution • Annual Incentive Bonus • Paid Time Off (PTO)