Utilization Management Specialist

Job Description We’re hiring a Utilization Management Specialist to join the Commercial Pharmacy Phone & UMS 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. What You’ll Do Conducts nonclinical 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 nonverbal 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