Clinical Specialist – Nonclinical

. Research simple to moderately complex requests and documentation related to utilization management processes and regulatory requirements .

Posted 10/15/2026full-timeRemote • United StatesJuniorMid-Level💰 $24 - $43 per hourWebsite

Key responsibilities & impact

Research simple to moderately complex requests and documentation related to utilization management processes and regulatory requirements
Review requests for completeness, obtain missing information, and prepare cases for clinical review
Complete nonclinical case tasks, including documenting critical information, initiating referrals, and accurately closing cases
Conduct telephonic and written outreach to providers to request medical records and communicate case determinations, cancellations, and other information
Manage time and follow guidelines to meet timeliness, production, quality, accuracy, federal, state, BCBSA, and accreditation standards
Communicate across teams and maintain organized access to reference materials, policies, and procedures
Uphold a professional, ethical, member-focused work environment
Identify workflow and system improvement opportunities
Assist with systems testing, coordinate case information in external vendor systems, or discuss service planning with providers

What you’ll need

High school diploma or equivalent and 2 years of clinical or hospital experience, or equivalent combination of education and experience
LPN, CMA or CNA preferred
Clinical experience, preferably in a hospital or health plan clinical services setting
Strong oral and written communication skills
Ability to work in a fast-paced environment while maintaining accuracy, confidentiality, and customer focus
Intermediate computer skills, including Microsoft Office, Outlook, and Internet search
Experience with health care systems and documentation, including EMR, billing, and claims
Knowledge of medical terminology, anatomy, and coding (CPT, DX, HCPCs)
Strong organization, data entry, and administrative skills
Ability to investigate and research complex UM case work issues and use critical thinking
Ability to work independently, prioritize work, meet deadlines, and achieve operational standards
Ability to work effectively in a team environment
Ability to perform UM Clinical Specialist duties and responsibilities
Ability to mentor coworkers and train new team members
Experience with AI tools and technologies highly desired
Personal mobile device required for MFA
Wired internet connection required; satellite or cellular internet is not accepted
Minimum internet speed of 5Mb upload and 10Mb download
Background check required

Comp & perks

5% bonus target
Medical, dental and vision coverage for employees and eligible family members, including mental health benefits
Annual employer contribution to a health savings account
Generous paid time off
10 company-paid holidays
401(k) company match
Potential discretionary retirement contribution based on company performance, with no vesting period
Up to 12 weeks of paid parental time off after 12 months of continuous service
Wellness programs that reward participation
Employee Assistance Fund
Commute and parking benefits
Work from home option
Flexible work option requiring wired internet service with minimum upload/download speeds
Company-supported outreach programs
Employee resource groups
Competitive base pay