Utilization Management Specialist

Description

We are in the healthcare industry, located in Durham, North Carolina, and we're looking to bring a Utilization Management Specialist on board. This role involves making outbound calls to members and providers to review medication requests, maintaining a strong focus on organization and confidentiality. The position is remote, with support provided in Eastern Standard Time, and offers a long-term contract employment opportunity.

Responsibilities

• Conduct non-clinical reviews based on applicable criteria and guidelines on requested services, ensuring that decisions are communicated to providers and/or members in line with department protocols.
• Complete verbal or non-verbal outreach to providers or members to gather medical information necessary for reviews.
• Maintain accurate customer credit records, ensuring accuracy to avoid impacting claims payment.
• Support the care management department by making outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards.
• Serve as a subject matter expert for CM& O around the non-clinical review process.
• Process customer credit applications accurately and efficiently.
• Identify and refer organization determinations that require a clinical review to a nurse or Medical Director.
• Utilize various systems including RX Claims MHR Care Radius FACETS MS Office and Genesis for work processes.
• Exhibit strong problem-solving skills while navigating multiple systems.
• Adhere to confidentiality protocols while self-managing remotely.
  
  

Requirements

• Demonstrated proficiency in customer service
• Experience in providing training
• Familiarity with review processes
• Ability to handle inbound and outbound calls
• Knowledge of medical coverage and healthcare.gov protocols
• Experience in hiring processes and claim administration
• Proficiency in call center customer service
• Understanding of financial notes and metric reporting
• Experience in clinical trial operations and maintaining confidentiality
• Ability to handle authorizations and ensure accuracy
• Knowledge of Medicare, pharmacy, and prescription processes
• A plus certification is an added advantage
• Proven experience as a subject matter expert
• Skills in language interpretation
• Familiarity with Content Management System (CMS) and Facets
• Knowledge of review processes
• Ability to adhere to protocols and maintain confidentiality.
  
  

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

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All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit

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