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Utilization Management & Quality Review Specialist

University of California - Los Angeles Health
United States, California, Los Angeles
Nov 24, 2024
Description

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

Qualifications 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
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