Utilization Management & Quality Review Specialist

General Information

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Work Location: Los Angeles, USA Onsite or Remote Flexible Hybrid Work Schedule Monday-Friday, 8:00am-5:00pm PST Posted Date 10/30/2024 Salary Range: $31.45 - 43.17 Hourly Employment Type 2 - Staff: Career Duration Indefinite Job # 20144

Primary Duties and Responsibilities

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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

Job Qualifications

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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