Utilization Management Specialist Job Description

Job Title:

Utilization Management Specialist

Shift:

8 am-5 pm

Duration:

6 months, with the possibility of extension based on the needs of the business.

Location:

Remote role with support in EST from an approved conversion State. (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)

Job Description:

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. Nice to have medical/healthcare industry experience. Familiar with any of the following is nice to have: Nuxeo, Genesys, Care Radius, Facets. Excellent Customer Service and attention to detail. Making calls - need to have good call control and the ability to de-escalate when needed. Microsoft Suite.

About Us:

 Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust

ISO 9001

2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation.

SPECTRAFORCE

is built on a concept of "human connection," defined by our branding attitude of

NEWJOBPHORIA

®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential.

Learn more at:

http://www.spectraforce.com

Benefits:

SPECTRAFORCE

offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program.

SPECTRAFORCE

provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer:

 

SPECTRAFORCE

is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at [email protected] if you require reasonable accommodation.

California Applicant Notice:

SPECTRAFORCE

is committed to complying with the California Privacy Rights Act ("CPRA") effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting [email protected].

LA County, CA Applicant Notice:

If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer. At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $25.84/hr.