Utilization Management Specialist

Blue Cross NC

. Conduct nonclinical reviews based on applicable criteria and guidelines for requested services .

Posted 10/23/2026full-timeRemote • North Carolina • United StatesMid-LevelSenior💰 $45,761 - $73,217 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting nonclinical reviews and communicating outcomes effectively while adhering to departmental protocols. Proficient in analyzing nonclinical information and supporting care management processes in compliance with CMS standards.

Highest-signal resume keywords

Nonclinical Review ProcessHealthcare Customer ServiceClaims Payment AccuracyCommunication Skills3+ Years Experience

ATS Keywords

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Applicant Tracking System Keywords

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Soft Skills

Communication SkillsCustomer Service Skills

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

HealthcareMedical InformationCare ManagementCMS StandardsCall Center Experience

About the role

Key responsibilities & impact

Conduct nonclinical reviews based on applicable criteria and guidelines for requested services
Communicate decisions to providers and/or members according to department protocols
Document review outcomes and interpret and analyze nonclinical information
Complete verbal or nonverbal outreach to providers or members to obtain medical information
Identify and refer organization determinations requiring clinical review to a nurse or Medical Director
Review authorizations for accuracy to avoid impacting claims payment
Support care management outreaches to meet CMS information-solicitation and notification standards
Retrieve and attach facsimiles for administrative processing
Serve as a subject matter expert on the nonclinical review process

Requirements

What you’ll need

High school diploma or GED
3+ years of experience in a related field
Call center experience is a plus
Customer service experience in the healthcare/medical space is a plus

Benefits

Comp & perks

Work-life balance, flexibility, and autonomy
Medical, dental, and vision coverage
Health and wellness programs
Parental leave and support
Adoption and surrogacy assistance
Career development programs
Tuition reimbursement for continued education
401(k) match including an annual company contribution
Paid Time Off (PTO)
Annual Incentive Bonus based on annual corporate goal achievement and individual performance
Competitive health benefits and wellness programs