Location: Exeter, NH/ South Burlington, VT/ Hybrid/ Remote

Employment Status: Full-time

FLSA Status: Non-Exempt 

Reports To: Utilization Review Process Manager

Job Summary: 

Under the supervision of the Utilization Review Process Manager, the Utilization Review Specialist will use professional discretion and judgment to prepare and coordinate reviews of group renewal information as needed at each group’s renewal time, as well as upon special request. You will review claims submitted to UR Queues for medical necessity, for on file/not on file authorizations. Make determinations for claims processing based upon coding.  This position involves interpretation of medical data, coordination of review processes, and collaboration with clinical and administrative teams to support effective utilization management. 

Key Responsibilities:

• Processes incoming and outgoing correspondence/faxes as assigned in accordance with required standards and within respective timeliness guidelines. Referring to the appropriate clinical team members for review as defined by workflow, when relating to claims or TOC outreach.

• Clerical responsibilities such as processing urgent scanning, and document retrieval when relating to claims routed to UR.

• Demonstrates a professional and courteous manner when communicating with others with the ability to state clearly and accurately the agreed upon resolution.

• Adhere to Standard Operating Procedures and maintains current knowledge of member benefits, rights and responsibilities.

• Performs other related duties and projects as assigned within the assigned timeframes.

• Interprets Plan language and applies to specialist tasks.

• Adheres to company policies and procedures.

• Processes claims, within BCBS association standards, a knowledge of these standards required. 

Required Qualifications

• One (1) or more years of experience in a healthcare payer, third-party administrator (TPA), utilization management/utilization review, health insurance, claims administration, or related healthcare environment.

• Experience reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteria.

• Ability to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to support claims and utilization review decisions.

• Working knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems.

• Strong analytical and critical-thinking skills with the ability to make accurate, well-reasoned determinations based on available documentation.

• Proficiency with Microsoft Office applications, including Word, Excel, and Outlook, and the ability to learn new systems and technology quickly.

• Excellent written and verbal communication skills and the ability to interact professionally with providers, members, and internal stakeholders.

Preferred Qualifications

• Experience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions.

• Experience with BCBS Association guidelines, utilization management workflows, or health plan operations.

• Experience using Javelina or other healthcare claims and case management systems.

• Medical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical background.

• CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.