Utilization Management Specialist
Durham, NC
100% Remote
Contract
$17/hr - $17/hr
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
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
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.
- 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
You will receive the following benefits:
- Medical Insurance - Four medical plans to choose from for you and your family
- Dental & Orthodontia Benefits
- Vision Benefits
- Health Savings Account (HSA)
- Health and Dependent Care Flexible Spending Accounts
- Voluntary Life Insurance, Long-Term & Short-Term Disability Insurance
- Hospital Indemnity Insurance
- 401(k) including match with pre and post-tax options
- Paid Sick Time Leave
- Legal and Identity Protection Plans
- Pre-tax Commuter Benefit
- 529 College Saver Plan
Motion Recruitment Partners (MRP) is an Equal Opportunity Employer, including Veterans/Disability/Women. All applicants must be currently authorized to work on a full-time basis in the country for which they are applying, and no sponsorship is currently available. Employment is subject to the successful completion of a pre-employment screening. Accommodation will be provided in all parts of the hiring process as required under MRP’s Employment Accommodation policy. Applicants need to make their needs known in advance.