Full-Time Healthcare Utilization Specialist

• Review claims in utilization review queues for medical necessity and authorization status; determine appropriate processing based on coding and plan language.
• Support the daily operations of the Utilization Review department by assisting senior UR team members with case review activities.
• Conduct outreach calls and collect data using established scripts, tools, and protocols, while maintaining productivity and service standards.
• Process correspondence and faxes in accordance with timeliness standards; escalate to clinical team members when appropriate.
• Perform clerical and administrative tasks, including scanning, document retrieval, and urgent claims processing support.
• Communicate clearly, professionally, and courteously with internal and external stakeholders to resolve issues.
• Provide written direction to other team members (nurses, claims auditors) to support accurate claims processing.
• Maintain current knowledge of Standard Operating Procedures, member benefits, rights, and responsibilities.
• Ensure compliance with BCBS Association standards and company policies.
• Complete other related duties and projects as assigned.

• Medical assistant, home health aide, nursing assistant, or other similar health care para-professional training or certification.
• Fluent computer skills including MS Office (Word, Excel, and Outlook) and Internet applications.
• Strong reading comprehension
• Self-motivated, self-directed, operates without constant guidance.
• Must be able to make sound logical decisions and articulate the reasoning.

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