Utilization Management Specialist

Our client, the largest health care industry, is seeking a utilization management specialist to join their team. If you are detail-oriented, experienced in customer service or call center environments, and have a healthcare or pharmacy background, we encourage you to apply for this remote opportunity.

Job Title: Utilization Management Specialist

Location: REMOTE

Pay Range: $24/hr on w2

What's the Job?

Position Overview: We are seeking highly organized and self-motivated candidates for a remote, non-clinical review specialist role. The successful candidate will primarily make outbound calls to members and providers to review medication requests and provide decisions on prescription drug coverage. A pharmacy background is a plus, along with experience working in healthcare or call center environments.

Key Responsibilities:

• Conduct non-clinical reviews based on applicable guidelines and criteria for requested services.
• Communicate decisions to providers or members following department protocols.
• Document review outcomes, interpreting and analyzing non-clinical information as required.
• Conduct outreach (verbal or non-verbal) to obtain medical information necessary for reviews.
• Identify and refer cases requiring clinical review to nurses or medical directors.
• Perform authorization reviews to ensure accuracy and prevent claim payment issues.
• Support the Care Management team in meeting CMS requirements by completing outreach for soliciting information or notification.
• Assist the administrative support team by retrieving and attaching facsimiles, ensuring customer requests are routed to the correct department.
• Act as a subject matter expert on the non-clinical review process within the Care Management & Operations (CM&O) department.

Job Requirements:

• High school diploma or GED required.
• Minimum of 3 years of experience in a related field.
• Outbound call or call center experience required.
• Pharmacy experience as a pharmacy technician or similar experience working in a pharmacy is highly preferred.
• Ability to manage and navigate multiple systems, including RX Claims, MHK, CareRadius, FACETS, Microsoft Office, and Genesis.
• Strong problem-solving skills, attention to detail, and ability to work independently.
• Empathy, confidentiality, and professionalism when dealing with sensitive member and provider information.
• Strong work history, with at least 1 to 2 years at previous jobs, avoiding job hopping.

Additional Information:

• Remote position, supporting in EST from an approved state.
• 6-month assignment with the possibility of extension based on business needs.
• Training will last for 2 weeks (on camera), after which on-camera presence will not be required.
• Expected to handle 35-40 calls daily, with a target of 6-8 calls per hour.
• The interview process will be a single interview with Kae and Holly.

Ideal Candidate:

• Experience using MHK (preferred).
• Strong communication skills and ability to self-manage in a remote environment.
• Experience in the healthcare field and pharmacy background is a significant advantage.

If this is a role that interests you and you'd like to learn more, click apply now and a recruiter will be in touch with you to discuss this great opportunity. We look forward to speaking with you!

About ManpowerGroup, Parent Company of:Manpower, Experis, Talent Solutions, and Jefferson Wells

ManpowerGroup® (NYSE: MAN), the leading global workforce solutions company, helps organizations transform in a fast-changing world of work by sourcing, assessing, developing, and managing the talent that enables them to win. We develop innovative solutions for hundreds of thousands of organizations every year, providing them with skilled talent while finding meaningful, sustainable employment for millions of people across a wide range of industries and skills. Our expert family of brands - Manpower, Experis, Talent Solutions, and Jefferson Wells - creates substantial value for candidates and clients across more than 75 countries and territories and has done so for over 70 years. We are recognized consistently for our diversity - as a best place to work for Women, Inclusion, Equality and Disability and in 2022 ManpowerGroup was named one of the World's Most Ethical Companies for the 13th year - all confirming our position as the brand of choice for in-demand talent.