Hiring: Utilization Management Specialist Company: Blue Cross NC Location: Raleigh-Durham-Chapel Hill Area Job Posted Time: 2026-09-17 02:51:02 Employment Type: Remote Target Skills & Keywords : Medicaid, Medicare About the job Experience: •3+ years of experience in related field. Required Skills: •Conducts nonclinical reviews based on applicable criteria and guidelines on requested services. Communicates decision to provider and/or member, according to department protocols. •Documents outcome of reviews and demonstrates the ability to interpret and analyze the non-clinical information. •Completes verbal or nonverbal outreach to providers or members to obtain the medical information for the review. •Identifies and refers organization determinations that require a clinical review to a nurse or Medical Director. •Conducts reviews of authorizations entered to ensure accuracy to avoid impacting claims payment. •Supports the care management department by completing outreaches to members or providers to meet The Centers for Medicare & Medicaid Services (CMS) requirement for soliciting information or notification standards. •Supports the administrative support team with the retrieval and attachment of facsimiles to ensure customer requests are forwarded to the respective area for processing. •Serves as a subject matter expert for CM&O around the non-clinical review process. Qualifications: •High school diploma or GED •Call center experience is a plus. •Customer service experience in the healthcare/medical space is a plus. •The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community •Work-life balance, flexibility, and the autonomy to do great work •Medical, dental, and vision coverage along with numerous health and wellness programs •Parental leave and support plus adoption and surrogacy assistance •Career development programs and tuition reimbursement for continued education •401k match including an annual company contribution •Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused. Compensation: •$45,761 - $73,217 / year Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!