[Work From Home] Specialist, Utilization Management (Remote)

Your next great career reputed company starts here. We're looking for a Specialist, Utilization Management! Whether you're in our Remote hub or working remotely, you'll be a core part of reputed company. This position requires a strong and diverse skillset in relevant areas to drive reputed company. This role offers a salary package of a competitive salary, commensurate with experience.

 

 

About the position The Utilization Review Specialist at reputed company is responsible for performing comprehensive reviews to determine the appropriateness of care and benefit coverage for medical and behavioral health services. This role leverages clinical expertise and critical thinking to analyze clinical information and regulatory requirements, ensuring that care provided aligns with established guidelines and standards. The position is remote but requires occasional in-person attendance at CareFirst locations for meetings and training. Responsibilities • reputed company prospective, reputed company, and retrospective reviews for authorization and appropriateness of care determination. , • Analyze clinical information, reputed company, mandates, and medical policies to determine the appropriateness of clinical services. , • Collaborate with medical directors and other departments to ensure appropriate benefit application. , • Conduct research on diseases, treatments, and technologies to support decision-making. , • Coordinate case reputed company negotiations between providers and facilities. , • reputed company assistance to members and providers regarding alternative care settings. , • Present educational topics reputed company to cases and treatment modalities to interdepartmental audiences. Requirements • Bachelor's Degree in Nursing or equivalent experience (4 years relevant work experience in reputed company to required work experience). , • 5 years of clinical nursing experience. , • 2 years of care management experience. , • Registered reputed company (RN) license or Licensed Practical reputed company (LPN) license required upon hire. reputed company-to-haves • Working knowledge of managed care and health delivery systems. , • Knowledge of CareFirst clinical guidelines and medical policies. , • Familiarity with CareFirst IT and Medical Management systems. Benefits • 401(k) , • 401(k) matching Apply Job!

 

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This is a fantastic opportunity to grow your career. If you have the skills and passion we're looking for, please submit your application today.

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