Utilization Management Specialist # 26-26425

Job Description

Job Description

Duration: 06 Months

Job Summary:

• Under the direction of the Precertification Team Manager, the Utilization Management (UM) Specialist is responsible for managing daily non-clinical review activities that support the clinical, business, and operational functions of the Utilization Management department.
• The UM Specialist coordinates coverage determinations for designated products and accounts, prepares and edits medical necessity denial letters, and monitors daily processes performed by coordinators. This role works closely with internal departments, healthcare providers, hospitals, and provider office staff to ensure quality, accuracy, compliance, and timely resolution of issues.

Key Responsibilities

• Write and edit medical necessity denial letters.
• Participate in structured training programs for new staff.
• Assist in training existing employees on new procedures, processes, and systems.
• Conduct staff audits and support monitoring activities to ensure the quality and accuracy of coordinators’ work.
• Coordinate coverage determinations for designated products and accounts.
• Assist partner departments in resolving claims discrepancies and misdirected activities.
• Investigate root causes of operational issues and recommend appropriate solutions.
• Support departmental administrative activities, information requests, and follow-ups.
• Participate in projects and special assignments to meet departmental deadlines and compliance requirements.
• Represent the department on committees as requested.
• Communicate regularly with network providers, hospital contacts, provider office staff, and internal departments.
• Perform other duties and responsibilities as assigned.

Required Qualifications & Education

• Bachelor’s degree or equivalent relevant work experience.

Experience

• Minimum of 3 years of experience in a managed care or healthcare industry environment.

Skills and Competencies

• Excellent written and verbal communication skills.
• Proficiency and accuracy in data entry across multiple applications.
• Ability to identify urgent situations and follow established protocols.
• Strong organizational, analytical, problem-solving, and conflict-resolution skills.
• Ability to manage multiple priorities in a complex and sensitive work environment.
• Strong attention to detail and commitment to quality and accuracy.
• Self-motivated, proactive, and capable of working independently.
• Excellent interpersonal and customer service skills.
• Ability to collaborate effectively with healthcare providers, hospitals, and internal stakeholders.

Location: Remote (Canton, MA)
Candidate Location: Locals to New England states such as MA, RI, CT, NH, ME, VT preferred

About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.

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