Utilization Management & Quality Review Specialist

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

* 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