Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Utilization Management Specialist.
They have over 4 million customers and 5,000+ employees dedicated to providing innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.
Location : While the position is Remote, work from home, you must reside in North Carolina or one of the following states : Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
Contract Duration : 6+ Months
Required Skills & Experience
- High school diploma or GED
- 3+ years of experience in related field.
- Outbound call experience, or call center experience
- Pharmacy experience as a Pharm tech or experience working in a pharmacy.
Desired Skills & Experience
- MHK experience
- Healthcare background
What You Will Be Doing
- 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.
To be eligible to contract at this client you must be able to pass a drug test and criminal background check
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