Job Title: Utilization Management Specialist Duration: 12 months Shift: 8 am-5 pm Location: Remote role with support in EST from an approved conversion State. (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.) | STRONG PREFERENCE FOR NC
Job Description:
Conducts non-clinical reviews based on applicable criteria and guidelines on requested services.
Communicates decisions 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 fields.
Top 3-4 Required Skills:
High volume experience.
UM experience.
Strong attention to detail.
Nice to have Skills:
Retail Pharm Tech.
Medicare Exp.
Industry Specific Experience – required, ideal, necessary?
Healthcare insurance.
Retail Pharmacy.
What is this role’s main focus for the 1st 90 days?
First month is training.
Second month will be work done with quality checks.
Breakdown of Duties/Typical Day:
They will be answering periodic calls that come through from the Tier 1 call team.
They will also be working through prior authorization from faxes.
They will be in a portal where they might need to reach out to members to inform them of being approved, not picking up medicine.
What does the training look like for this role?
3-4 weeks, sitting with trainers and shadowing others.
Applicant Notices & Disclaimers
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $25.84/hr - $27.56/hr.
