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TEKsystems · 6 hours ago

Utilization Review Specialist

Canoga Park, CA

Contract

Hybrid

Entry, Mid Level

$35/hr - $50/hr

2+ years exp

TEKsystems is a leading provider of business and technology services, and they are seeking a Retro Claims Reviewer. The role involves auditing and reviewing medical claims to ensure accuracy, regulatory compliance, and proper adjudication, ideal for candidates with experience in Utilization Management and HMO/Medicare claims processes.

Information Technology

Responsibilities

Audit denied provider and member claims for accuracy and compliance

Review and process claims in accordance with UM guidelines and regulatory standards

Analyze benefit structures and system configurations (EZCap or similar)

Collaborate with cross-functional teams to resolve claim issues and process gaps

Document findings, prepare reports, and present trends to leadership

Support automated adjudication systems and identify strategies to reduce errors

Ensure HIPAA and PHI compliance throughout all claim review activities

Participate in special projects related to claim denials and appeals

Qualification

Utilization Management (UM)HMO/Medicare claimsClaims processing systemsCPT coding knowledgeICD-10 coding knowledgeAdvanced Excel skillsAnalytical skillsMS Office SuiteDocumentation skillsCommunication skillsIndependent work