Utilization Management Specialist

Job Description:

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Leveraging clinical expertise and critical thinking skills, the specialist will analyze clinical information, contracts, mandates, medical policies, evidence-based research, national accreditation, and regulatory requirements to determine appropriateness and authorization of medical and behavioral health services.

Desired Start Date: April 7, 2025
Duration: 9 Months
Hours per Week: 40
Location: Hybrid (Candidate must reside within DMV and be required to come to Canton)
Pay Rate: $40 - $43 per hour

Essential Functions:

Medical Necessity & Appropriateness Determination:

• Reference regulatory mandates, contracts, benefit information, and industry guidelines (Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare, FEP, Medical Policy, etc.).
• Follow NCQA Standards, CareFirst Medical Policy, and departmental SOPs to manage member assignments.
• Understand CareFirst lines of business, including Commercial, FEP, and Medicare primary and secondary policies.

Research & Analysis:

• Conduct research on diseases, treatments, and emerging technologies, particularly high-cost/high-dollar services.
• Collaborate with medical directors, sales & marketing, contracting, and provider services to determine benefit applications.
• Apply clinical knowledge to case assessments.
• Coordinate non-par provider/facility case rate negotiations.

Referrals & Education:

• Make appropriate referrals for alternative care settings.
• Assist members and providers with alternative treatment options.
• Conduct educational presentations on disease entities, treatment modalities, and case studies.

Qualifications:

Education:

• Bachelor’s Degree in Nursing (Required)
• In lieu of a Bachelor’s Degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience:

• 5 years of clinical nursing experience
• 2 years of care management experience

Preferred Qualifications:

• Working knowledge of managed care and health delivery systems
• Thorough knowledge of CareFirst clinical guidelines, medical policies, accreditation, and regulatory standards
• Familiarity with CareFirst IT and Medical Management systems

Knowledge and Skills:

• Strong written and interpersonal communication skills
• Ability to make rapid telephonic connections with members
• Experience handling confidential member data and PHI
• Ability to prioritize workload during peak periods
• Proficiency in multitasking and organization
• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint)
• Excellent analytical and problem-solving skills
• Ability to adapt to a fast-paced environment with shifting priorities and deadlines

Licenses/Certifications (Required):

• RN - Registered Nurse - State Licensure and/or Compact State Licensure or
• LPN - Licensed Practical Nurse - State Licensure or
• CNS - Clinical Nurse Specialist (Preferred)

Additional Requirements:

• Candidate must reside within the DMV area.
• This hybrid role requires in-office attendance in Canton as needed.
• The incumbent must immediately disclose any debarment, exclusion, or other events that may affect eligibility to work on federal healthcare programs.

Application Process:

Interested candidates should submit their resume and cover letter to wakeju@korakglobal.com

Job Types: Full-time, Contract

Pay: From $57,600.00 per year

Benefits:

• 401(k) matching

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: Remote

Salary : $57,600