Utilization Management Specialist

Blue Cross NC

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

Posted 9/16/2026full-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 decisions effectively to providers and members. Proficient in documenting and analyzing non-clinical information while ensuring compliance with departmental protocols and standards.

Highest-signal resume keywords

Nonclinical ReviewCommunication SkillsDocumentation and AnalysisCustomer Service ExperienceAuthorization Review

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Nonclinical Review ProcessDocument InterpretationMedical Information RetrievalAuthorization Accuracy ReviewFacsimile Attachment

Soft Skills

Verbal CommunicationOutreach Skills

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

HealthcareCMS StandardsClaims PaymentCall Center Experience

About the role

Key responsibilities & impact

Conduct nonclinical reviews of requested services based on applicable criteria and guidelines
Communicate review decisions to providers and/or members according to department protocols
Document review outcomes and interpret and analyze non-clinical information
Contact providers or members to obtain medical information for reviews
Identify and refer organization determinations requiring clinical review to a nurse or Medical Director
Review authorizations for accuracy to help avoid claims payment impacts
Complete outreach to members or providers to support CMS information solicitation and notification standards
Retrieve and attach facsimiles and forward customer requests to the appropriate processing area
Serve as a subject matter expert for CM&O on the non-clinical review process
Provide administrative support to help meet departmental turnaround times

Requirements

What you’ll need

High school diploma or GED
3+ years of experience in related field
Call center experience is a plus
Customer service experience in the healthcare/medical space is a plus
Ability to conduct nonclinical reviews based on applicable criteria and guidelines
Ability to communicate decisions to providers and/or members according to department protocols
Ability to document, interpret, and analyze non-clinical information
Ability to conduct verbal or nonverbal outreach to providers or members
Ability to identify and refer organization determinations requiring clinical review
Ability to review authorizations for accuracy
Ability to retrieve and attach facsimiles

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
Annual Incentive Bonus
Paid Time Off (PTO)