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