Utilization Management Specialist

Job Summary

The Utilization Management Specialist will perform reviews for authorization, appropriateness of care determination, and benefit coverage using key principles of utilization management. They will analyze clinical information, contracts, mandates, medical policy, evidence-based research, and regulatory requirements.

Key Responsibilities

• Determine medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, guidelines, and other references.
• Follow NCQA Standards, client Medical Policy, and departmental SOPS to manage member assignments.
• Conduct research and analysis of pertinent diseases, treatments, and emerging technologies to support decisions and recommendations.
• Collaborate with medical directors, sales and marketing, contracting, provider, and member services to determine appropriate benefit application.
• Apply clinical knowledge and judgment throughout the review process.
• Make appropriate referrals and contacts as needed.
• Offer assistance to members and providers for alternative care settings.
• Research and present educational topics related to cases, disease entities, and treatment modalities to interdepartmental audiences.

Required Qualifications

• Bachelor's Degree in Nursing or 4 years of relevant work experience in lieu of a degree.
• 5 years of clinical nursing experience and 2 years of care management experience.
• RN/LPN state licensing or compact.
• Working knowledge of managed care and health delivery systems.
• Effective written and interpersonal communication skills, strong assessment skills, and proficiency in web-based technology and Microsoft Office applications.
• Ability to work effectively with confidential member data, prioritize workload, multitask, and maintain a dynamic personal organization system.

Pay

TBD

Schedule

Remote

Benefits

N/A

Skills

Not specified

Benefits

N/A

Pay

TBD

Schedule

Remote

Application Instructions

N/A

Equal Opportunity Employer

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.