Utilization Management Specialist

Job Summary

The Utilization Management Specialist is responsible for providing support for utilization management, care coordination and other preservice requests by receiving, reviewing and acting on requests from service providers for medical procedures, treatments or medications. This position may approve, reject or route to other staff per protocol.

 Essential Functions

• Receives and set up incoming preservice requests from service providers and refers cases to appropriate nursing staff for further review, if necessary.
• Documents and verifies eligibility, plan limitations, provider network and other parameters for requests. Enters request in one or more of multiple systems and logs information ensuring accuracy of data.
• Responds and resolves cases with scope of practice following standard communications protocols.
• Routes requests beyond scope of authority to appropriate staff for review and disposition.
• Manages and tracks peer-to-peer requests, logs information and tracks action steps.
• Collaborates with internal staff and external providers to provide outcome, refer to complimentary programs and provides additional instruction(s).
• Prioritizes workloads to ensure timeliness standards and inventory levels are maintained.
• Provides support performing system maintenance generating/analyzing ad hoc or regular activity reports, as requested.

Knowledge, Skills and Abilities

Attention to Detail and Accuracy

Intermediate

Communication (Verbal/Written)

Intermediate

Task and Goal Focus

Intermediate

Analytical Thinking

Basic

Effective Interpersonal Communications

Basic

Collaboration

Basic

 

 

 Education Requirements

Required: High School Diploma/GED

Preferred: Associate's

Field(s) of Study: General Studies, Business or related field

Experience Requirements

Required: Minimum of 1 Year

Preferred: Minimum of 2 Years

Experience Details: Minimum of 1 year medical office-setting, health insurance or related experience is required; knowledge of health insurance and medical terminology is strongly preferred.

 Certification, Licensures & Registration Requirements

Title: N/A

State or Agency: N/A

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Important Notice: BCBSND has a vaccination protocol in place that requires any employees who physically work in a BCBSND office or whose role requires direct customer contact to be vaccinated against COVID-19. We respect your choice to get vaccinated (or not) and getting vaccinated is not a condition of employment. If you are not vaccinated, you may work remotely if your role allows for it. If your role does not allow for remote work and you are unable to get the COVID-19 vaccine, there is an exception process available that includes a weekly testing regimen.

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com

This job posting will be closed 02/04/2022 at 8:00AM CST. No further applications will be considered.