Utilization Management Specialist

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives

We’re seeking Utilization Management Specialists to join the Government Pharmacy Utilization Management Operations Team! The Utilization Management Specialist is responsible for the completion of non-clinical reviews and communication to customers to support utilization management reviews and activities. The Utilization Management Specialist may also provide support for administrative functions within the department to support turnaround times. **Shift schedule: 8 AM – 5 PM EST, and includes rotating to cover weekend and holiday shifts**

Conduct non clinical reviews based on applicable criteria and guidelines on requested services. Communicate decision to provider and/or member, according to department protocols. Document outcome of reviews and demonstrate the ability to interpret and analyze the non-clinical information. Complete verbal or non verbal outreach to providers or members to obtain the medical information for the review. Identify and refer organization determinations that require a clinical review to a nurse or Medical Director. Conduct reviews of authorizations entered to ensure accuracy to avoid impacting claims payment. Support 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. Support the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing. Serve as a subject matter expert for CM&O around the non-clinical review process.