Description

Under the direction and supervision of the Utilization Management Manager, the Utilization Management Specialist is responsible for overseeing the research, resolution and workflow development of out-of-network (OON) referral requests. This role reviews OON referral requests from members and providers, acting as a key liaison to facilitate timely, accurate, and efficient processing. In addition, the UM Specialist will:

Ensure compliance with organizational guidelines and regulatory standards, promoting quality care access for members while optimizing network utilization and reducing unnecessary out-of-network expenses Collaborate closely with the network team to identify gaps in provider availability and propose suggestions for network expansion Be responsible for analyzing OON utilization data and developing trend reports that assist the network team with network gap closures Be able to work under general supervision, relying on instructions, work process guidelines, policies & procedures, and departmental company knowledge/experience to perform the functions of the job
Salary Range: $30.56 – $60.82 Hourly