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Utilization Management Specialist
2 months ago
At Health Care Service Corporation, our workforce is the foundation of our operations and the key to our achievements. We equip our team members with tailored development plans that encourage advancement and foster rewarding, fulfilling careers.
Position Overview
This role is pivotal in executing initial and ongoing review processes, as well as coordinating discharge care to assess the efficiency, effectiveness, and quality of medical and surgical services. The position acts as a liaison among healthcare providers and the medical and network management divisions.
Key Responsibilities:
- Gather and analyze clinical and non-clinical data.
- Confirm eligibility and determine benefit levels in accordance with contractual guidelines.
- Prepare comprehensive reports on quality of care and identify cases that require further attention.
- Provide essential information regarding utilization management protocols and operational procedures to members, providers, and facilities.
- Demonstrate a willingness and capability to travel as necessary.
Required Qualifications:
- Registered Nurse (RN) with a valid, current, and unrestricted license in the state of practice.
- Minimum of 3 years clinical experience in a physician's office, hospital/surgical environment, or health insurance organization.
- Proficient understanding of medical terminology and procedures.
- Strong verbal and written communication skills.
- Willingness and ability to travel.
Preferred Qualifications:
- RN Compact License
- Experience in utilization management
- MCG Certification
Work Environment: This position is remote.
Equal Opportunity Employment Statement:
Health Care Service Corporation is an Equal Opportunity Employment / Affirmative Action employer committed to fostering an inclusive workplace where the unique differences of our employees are embraced, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
Compensation:
Base Pay Range: $58,000 - $130,100.00
