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.
Posted Sep 17
Unit and setting
Utilization Review · Third Party Administrator
Term
Permanent Employment Status: Full-timeFull-time
Do you qualify?
Experience
1+ years in healthcare payer, TPA, UR/UM, health insurance, claims administration, or related healthcare environment
Experience
reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteriaExperience reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteria.
Also asks
ability to interpret and apply health plan language, benefit provisions, policies, and standard operating proceduresAbility to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to support claims and utilization review decisions.
Also asks
working knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systemsWorking knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems.
Also asks
analytical and critical-thinking skillsStrong analytical and critical-thinking skills with the ability to make accurate, well-reasoned determinations based on available documentation.
Also asks
proficiency with Microsoft Office applications, including Word, Excel, and OutlookProficiency with Microsoft Office applications, including Word, Excel, and Outlook, and the ability to learn new systems and technology quickly.
Also asks
written and verbal communication skillsExcellent written and verbal communication skills and the ability to interact professionally with providers, members, and internal stakeholders.
Also asks
knowledge of BCBS association standardsProcesses claims, within BCBS association standards, a knowledge of these standards required.
Preferred
Certification
CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certificationCPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.
Experience
Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functionsExperience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions.
Experience
BCBS Association guidelines, utilization management workflows, or health plan operationsExperience with BCBS Association guidelines, utilization management workflows, or health plan operations.
Experience
using Javelina or other healthcare claims and case management systemsExperience using Javelina or other healthcare claims and case management systems.
Also asks
Medical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical backgroundMedical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical background.
prepare and coordinate reviews of group renewal information
Day to day
review claims submitted to UR Queues for medical necessity and authorizationsYou will review claims submitted to UR Queues for medical necessity, for on file/not on file authorizations.
Day to day
make determinations for claims processing based upon codingMake determinations for claims processing based upon coding.
Day to day
support daily operations of Utilization Review by assisting Senior Utilization Review SpecialistSupports the daily operations of the Utilization Review department by assisting the Senior Utilization Review Specialist with various tasks.
Day to day
maintain knowledge base of UR processes and timelinesMaintains a current knowledge base of UR processes and timelines.
Day to day
conduct outreach calls and collect data according to script and protocols
Day to day
refer to appropriate staff when indicated by workflowRefers to appropriate staff when indicated by workflow.
Day to day
process incoming and outgoing correspondence and faxesProcesses incoming and outgoing correspondence/faxes as assigned in accordance with required standards and within respective timeliness guidelines.
Day to day
refer to clinical team members for review regarding claims or TOC outreachReferring to the appropriate clinical team members for review as defined by workflow, when relating to claims or TOC outreach.
Day to day
process urgent scanning and document retrieval for claims routed to URClerical responsibilities such as processing urgent scanning, and document retrieval when relating to claims routed to UR.
Day to day
communicate agreed upon resolutions clearly and accuratelyDemonstrates a professional and courteous manner when communicating with others with the ability to state clearly and accurately the agreed upon resolution.
Day to day
adhere to Standard Operating Procedures and maintain knowledge of member benefits, rights and responsibilitiesAdhere to Standard Operating Procedures and maintains current knowledge of member benefits, rights and responsibilities.
Day to day
perform other related duties and projectsPerforms other related duties and projects as assigned within the assigned timeframes.
Day to day
interpret Plan language and apply to specialist tasksInterprets Plan language and applies to specialist tasks.
Day to day
adhere to company policies and proceduresAdheres to company policies and procedures.
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
Supports the daily operations of the Utilization Review department by assisting the Senior Utilization Review Specialist with various tasks.
Maintains a current knowledge base of UR processes and timelines.
Uses good listening skills, conducts outreach calls, collects data according to script, tools, and protocols meeting both productivity and performance expectations as identified by manager. Conducts all calls in a courteous and customer service friendly manner. Refers to appropriate staff when indicated by workflow.
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.
Requirements
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.
Neighborhoods+Young professionals cluster in Hyde Park (historic bungalows, Walk Score 78, about $550K–$850K, 10–15 minutes downtown), Mueller (newer walkable retail, $400K–$800K+, 5–10 minutes), East Austin (arts and dining), South Lamar ($400K–$700K), SoCo/Bouldin, and Downtown condos. People who want yards and stronger suburban schools often choose Circle C Ranch ($500K–$800K, 20–30 minutes, Austin ISD), Avery Ranch ($350K–$600K, Round Rock ISD, 20–25 minutes), Steiner Ranch (lake access, Leander ISD, 25–35 minutes), or Allandale (larger lots, $500K–$750K). Family-budget mentions include Sunfield in Buda east of I-35, Garrison Park, Windsor Hills, Pflugerville, Cedar Park, and Round Rock. Luxury and walkability premiums sit in Clarksville, Zilker, Tarrytown, and West Lake Hills (Eanes ISD).
Young professionals cluster in Hyde Park (historic bungalows, Walk Score 78, about $550K–$850K, 10–15 minutes downtown), Mueller (newer walkable retail, $400K–$800K+, 5–10 minutes), East Austin (arts and dining), South Lamar ($400K–$700K), SoCo/Bouldin, and Downtown condos. People who want yards and stronger suburban schools often choose Circle C Ranch ($500K–$800K, 20–30 minutes, Austin ISD), Avery Ranch ($350K–$600K, Round Rock ISD, 20–25 minutes), Steiner Ranch (lake access, Leander ISD, 25–35 minutes), or Allandale (larger lots, $500K–$750K).
Family-budget mentions include Sunfield in Buda east of I-35, Garrison Park, Windsor Hills, Pflugerville, Cedar Park, and Round Rock. Luxury and walkability premiums sit in Clarksville, Zilker, Tarrytown, and West Lake Hills (Eanes ISD).
Getting around+Austin is car-centric: I-35 and MoPac are the main spines, public transit is limited, and drivers lose about 64 hours a year in traffic. Clarksville, Zilker, Mueller, and East Austin sit about 5–10 minutes from downtown; Hyde Park, Allandale, and South Lamar about 10–15; Circle C Ranch 20–30; Avery Ranch 20–25; Steiner Ranch 25–35. Cedar Park can reach the Domain in 15–20 minutes on a bad day; Pflugerville is the closest northern suburb on I-35; Dell-oriented commuters often live in Round Rock. Rush hour from Round Rock or Pflugerville is routinely described as painful; sources do not detail hospital-campus parking or named transit lines to specific medical centers.
Austin is car-centric: I-35 and MoPac are the main spines, public transit is limited, and drivers lose about 64 hours a year in traffic. Clarksville, Zilker, Mueller, and East Austin sit about 5–10 minutes from downtown; Hyde Park, Allandale, and South Lamar about 10–15; Circle C Ranch 20–30; Avery Ranch 20–25; Steiner Ranch 25–35. Cedar Park can reach the Domain in 15–20 minutes on a bad day; Pflugerville is the closest northern suburb on I-35; Dell-oriented commuters often live in Round Rock.
Rush hour from Round Rock or Pflugerville is routinely described as painful; sources do not detail hospital-campus parking or named transit lines to specific medical centers.
Outdoors+Central outdoor life is Zilker Park (351 acres), Barton Springs Pool, the Barton Creek Greenbelt, Pease Park, and the Lady Bird Lake Ann and Roy Butler Hike-and-Bike Trail—swimming, hiking, paddleboarding, and the Zilker Hillside Theater sit in walking or biking range of Zilker and Clarksville. From March through October, kayak tours watch the Congress Avenue Bridge bats at sunset. Weekends go to Pedernales Falls State Park, Westcave Discovery Center grotto tours ($20 for adults), and Muleshoe Bend Recreation Area for bluebonnets about 45 minutes out. Steiner Ranch adds lake living; the Colorado River cuts through the city. About 228 sunny days keep trails and water in play most of the year.
Central outdoor life is Zilker Park (351 acres), Barton Springs Pool, the Barton Creek Greenbelt, Pease Park, and the Lady Bird Lake Ann and Roy Butler Hike-and-Bike Trail—swimming, hiking, paddleboarding, and the Zilker Hillside Theater sit in walking or biking range of Zilker and Clarksville. From March through October, kayak tours watch the Congress Avenue Bridge bats at sunset.
Weekends go to Pedernales Falls State Park, Westcave Discovery Center grotto tours ($20 for adults), and Muleshoe Bend Recreation Area for bluebonnets about 45 minutes out. Steiner Ranch adds lake living; the Colorado River cuts through the city.
About 228 sunny days keep trails and water in play most of the year.
Check the commute at your shift’s start and end, upfront housing costs, and whether moving assistance must be repaid if you leave.
Living in Austin
Austin is distinct for live music from the Moody Theater to dive bars, Barton Springs inside 351-acre Zilker Park, Franklin Barbecue, and no state income tax—set against I-35 traffic, 100°F summers, cedar fever, and 2–2.5% property taxes. Nurses wanting a short hop to the core land in Mueller, Hyde Park, East Austin, South Lamar, or Allandale (5–15 minutes downtown). Those chasing yards and Round Rock, Leander, or Eanes schools look at Circle C Ranch, Avery Ranch, Steiner Ranch, Cedar Park, Round Rock, or Sunfield in Buda, with 20–35 minute drives. Metro homes sit near $500K and rents near $1,800; Windsor Hills and Garrison Park are cheaper footholds, Clarksville and West Lake Hills the luxury tier. Swim Barton Springs, kayak Lady Bird Lake for the Congress Bridge bats, hike Barton Creek Greenbelt, and catch ACL at Zilker or a set at Stubb's or the Continental Club. Spring and fall are glorious; August and rush hour are not. You generally get two of three: price, short commute, and top schools.
