Blue Cross NC · 12 hours ago
Utilization Management Specialist
United States
Full-time
Remote
Mid Level
$46K/yr - $73K/yr
3+ years expBlue Cross NC is seeking Utilization Management Specialists to join their Government Pharmacy Utilization Management Operations Team. The role involves conducting non-clinical reviews and communicating decisions to support utilization management activities, as well as providing administrative support within the department.
Financial ServicesHealth InsuranceInsurance
Responsibilities
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
Qualification
Required
High school diploma or GED
3+ years of experience in a related field
Preferred
Previous Utilization Management, pharmacy experience strongly preferred
Strong customer service and communication skills
Benefits
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
Company
Blue Cross NC
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.
5001-10000 employees
H1B Sponsorship
Blue Cross NC has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (4)
2024 (1)
2023 (2)
2022 (5)
2021 (13)
2020 (5)
Funding
Current Stage
Late StageLeadership Team
Tunde Sotunde
President and Chief Executive Officer
Caleb Davies
Medicaid Market CFO - Healthy Blue of NC Medicaid
Recent News
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