Utilization Management Specialist

Blue Cross NC

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

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 analyzing non-clinical information and ensuring compliance with healthcare policies and regulations.

Highest-signal resume keywords

Nonclinical ReviewHealthcare PoliciesUtilization ManagementMedical Billing and CodingCustomer Service Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Nonclinical ReviewDocumentation and AnalysisMedical Information RetrievalClaims Payment AccuracyOutreach Communication

Soft Skills

Effective CommunicationAnalytical ThinkingProblem Solving

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

HealthcareMedical ReviewCMS StandardsClinical ReviewCall Center Experience

About the role

Key responsibilities & impact

Conduct nonclinical reviews based on applicable criteria and guidelines for requested services
Communicate review decisions to providers and/or members according to department protocols
Document review outcomes and interpret and analyze non-clinical information
Conduct outreach to providers or members to obtain medical information
Identify and refer determinations requiring clinical review to a nurse or Medical Director
Review authorizations for accuracy to avoid impacts on claims payment
Support care management through member and provider outreach to meet CMS information solicitation and notification standards
Retrieve and attach facsimiles to forward customer requests for processing
Serve as a subject matter expert on the non-clinical review process for CM&O

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 and analyze non-clinical review information
Ability to conduct verbal or nonverbal outreach to providers or members
Ability to identify and refer organization determinations requiring clinical review
Knowledge of utilization management, healthcare policies, health care regulation, medical billing and coding, and medical information

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
401k match including an annual company contribution
Annual Incentive Bonus
Paid Time Off (PTO)