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Utilization Management Specialist

Perform ongoing reviews of patient medical records and history to monitor adherence to defined health plan and identify needs for additional care or services.

Keep abreast of subsequent treatment plan while ensuring appropriate and cost-effective healthcare services to patients.

Conducts any pre-certification requirements to evaluate member eligibility.

Qualifications

  • Prior utilization management/review experience is required.‬‬
  • Case Management experience is required, preferably in chronic care.
  • Experience working with Medicaid and/or Medicare managed care, including ‬regulatory and compliance requirements is required.