Utilization Management Specialist

• 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.