Utilization Management Specialist

Utilization Management Specialist Overview

• The Utilization Management Specialist role involves conducting non-clinical reviews based on applicable criteria and guidelines for requested services.
• Communicate decisions to providers and members following established department protocols and standards.
• Document review outcomes, interpreting and analyzing non-clinical information effectively.
• Perform outreach to providers or members to obtain necessary medical information for reviews.
• Refer cases requiring clinical review to nurses or Medical Directors for further evaluation.
• Ensure authorization reviews are accurate to prevent claims payment issues.
• Support care management by completing outreach to meet CMS notification standards.
• Assist administrative teams in processing customer requests efficiently and accurately.
• Act as a subject matter expert for non-clinical review processes within the organization.

Utilization Management Specialist Key Responsibilities & Duties

• Conduct non-clinical reviews using established criteria and guidelines for service requests.
• Communicate review outcomes to providers and members following department protocols.
• Document and analyze non-clinical information effectively during the review process.
• Perform outreach to obtain required medical information for accurate reviews.
• Refer cases needing clinical review to appropriate medical personnel.
• Review authorization entries to ensure accuracy and prevent claim issues.
• Support care management outreach to comply with CMS standards.
• Assist administrative teams in processing requests and attaching necessary documentation.
• Provide expertise in non-clinical review processes to enhance operational efficiency.

Utilization Management Specialist Job Requirements

• High school diploma or GED is required for this position.
• Minimum of 3 years of experience in a related field is mandatory.
• Preferred candidates will have 5 years of relevant experience.
• Strong ability to interpret and analyze non-clinical information effectively.
• Proficiency in conducting outreach to providers and members for information gathering.
• Experience in supporting care management and administrative teams in compliance tasks.
• Knowledge of CMS notification standards and requirements is advantageous.
• Capable of acting as a subject matter expert in non-clinical review processes.
• Ability to work remotely and independently in a contract-based role.