Utilization Management Specialist

Blue Cross and Blue Shield of North Carolina

2d • Hybrid

About The Position

The Utilization Management Specialist is responsible for the completion of non-clinical reviews and communication to customers to support utilization management reviews and activities. The Utilization Management Specialist may also provide support for administrative functions within the department to support turnaround times. What You'll Do • Conducts non clinical 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 demonstrates the ability to interpret and analyze the non-clinical information. • Completes verbal or non verbal outreach to providers or members to obtain the medical information for the review. • Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director. • Conducts reviews of authorizations entered to ensure accuracy to avoid impacting claims payment. • Supports the care management department by completing outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards. • Supports the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing. • Serves as a subject matter expert for CM&O around the non-clinical review process. Hiring Requirements • High school diploma or GED • 3+ years of experience in related field. What You’ll Get The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community Work-life balance, flexibility, and the autonomy to do great work Medical, dental, and vision coverage along with numerous health and wellness programs Parental leave and support plus adoption and surrogacy assistance Career development programs and tuition reimbursement for continued education 401k match including an annual company contribution #LI-DNI Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. Based on annual corporate goal achievement and individual performance. $45,761.00 - $73,217.00 Skills About Us It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives. Authorization to Work in the United States We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview for English or Visión General de E-Verify for Español. Request Accommodations Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at [e-mail]. For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming Much more than a paycheck The total value of working at Blue Cross NC goes far beyond your paycheck. We offer benefits and perks that help you thrive, such as competitive health benefits, bonus plans based on performance, 401(k) with employer match, paid time off (plus two well-being days), and a variety of career development and wellness programs.

Requirements

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

Responsibilities

• Conducts non clinical 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 demonstrates the ability to interpret and analyze the non-clinical information.
• Completes verbal or non verbal outreach to providers or members to obtain the medical information for the review.
• Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director.
• Conducts reviews of authorizations entered to ensure accuracy to avoid impacting claims payment.
• Supports the care management department by completing outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards.
• Supports the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing.
• Serves as a subject matter expert for CM&O around the non-clinical review process.

Benefits

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution
• Annual Incentive Bonus
• Paid Time Off (PTO)
• competitive health benefits and wellness programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED