Santa Maria, California
Abilene, Texas
Clarksdale, Mississippi
Baltimore, Maryland
Northeastern, Indiana
Posted: 31-Oct-24
Location: Los Angeles, California
Salary: Open
Categories:
Internal Number: 144039236
As the Utilization Management & Quality Review Specialist, you will be responsible for:
- Managing service requests and potential quality issue cases, ensuring compliance with regulatory requirements for both utilization management and quality assurance processes
- Ensuring that all cases are processed within mandated timeframes and that clear, timely communication is provided to all stakeholders.
- Working closely with medical director, utilization management and quality review team to ensure that all cases are handled effectively.
- Other duties as assigned
Salary Range: $31.45 - $43.17/hourly
We’re seeking a detail-oriented individual with:
• Bachelor’s degree in a healthcare-related field or equivalent experience
• Two or more years of experience in healthcare operations, managed care, or Medicare Advantage, preferably handling utilization management and PQI (potential quality issues)
• Experience in interpreting CMS guidelines and working with regulatory requirements, highly desired
• Strong knowledge of Medicare Advantage plans, CMS regulations, and the utilization management and PQI processes.
• Excellent verbal and written communication skills
• Ability to handle sensitive and confidential information with discretion
• Proficiency with case management software and Microsoft Office application
