Utilization Management Claims Specialist

Join the VitalCore Team in Massachusetts! We're people who are fueled by passion, not by profit. VitalCore Health Strategies, (VCHS), an industry leader in Correctional Healthcare, has an opening for a Full-Time Utilization Management Claims Specialist at the Regional Office in Hopkinton, MA. Looking for a rewarding career in the field of healthcare? At VitalCore we pride ourselves on retaining and acquiring hardworking ethical individuals who are committed to providing quality services. Join our team and experience first‑hand how VitalCore Health Strategies promotes a positive work environment that is based on respect and appreciation of the hard work and dedication of our staff. Utilization Management Claims Specialist Benefits Holiday Pay: New Year’s Day, Martin Luther King Jr. Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Veteran’s Day, Thanksgiving Day, and Christmas Day Medical Dental Vision Health Savings Account Dependent Care Flexible Spending Account Life Insurance Short Term/Long Term Disability Identity Theft Protection Pet Insurance Employee Assistance Program and Discount Center 401K & Plan Matching PTO Utilization Management Claims Specialist Position Summary The Utilization Management Claims Specialist is responsible for reviewing and evaluating off‑site healthcare service claims for accuracy, completeness, and compliance with organizational and contractual policies and regulatory guidelines. Utilization Management Claims Specialist Essential Functions Ensure the accurate flow of medical information between patients, external providers, and third‑party payers. Enter, research, and analyze data to ensure accuracy and support reimbursement processes. Identify potential billing errors, duplicate claims, fraud, waste, or abuse and escalate concerns as appropriate. Utilize established criteria to conduct preliminary reviews for services requiring prior authorization. Assess the need for additional information to support service authorization decisions. Maintain accurate records of claim reviews, determinations, and related correspondence. Collaborate with clinical and administrative teams to support efficient claims processing and quality outcomes. Process requests for authorization reviews and data verification in a timely and efficient manner. Adhere to departmental and organizational policies and procedures, and all applicable regulatory, contractual, and compliance requirements. Maintain proficiency in Microsoft Office applications, including Excel, and other required technology platforms. Demonstrate strong customer service skills, including effective communication, patience, empathy, and professionalism. Apply problem‑solving and critical thinking skills to resolve issues and support decision‑making. Maintain knowledge of CPT and ICD coding requirements. Interpret and apply medical coding, reimbursement policies, and utilization management guidelines. Work effectively both independently and collaboratively within a team environment. Safeguard patient confidentiality and comply with all HIPAA requirements. Perform other duties as assigned. Utilization Management Claims Specialist Minimum Requirements Associate’s degree or equivalent experience – Bachelor’s degree preferred. Has an active certification in Medical Coding or equivalent experience. 5+ years professional work experience in healthcare, managed care, or insurance preferred. Education, training, or experience as a medical coder, medical billing, or insurance coordinator required. Demonstrate proficiency in the English language, including reading, writing, speaking, and comprehension skills. Function as a supportive team member by contributing to a collaborative and positive team environment. Exercise sound judgment and make independent decisions when appropriate. Interact professionally and tactfully with staff, family members, visitors, government agencies, and the general public. Exhibit leadership and supervisory skills while working effectively and harmoniously with others. Maintain a safe and professional work environment and perform duties in a manner that does not pose a direct threat to the health or safety of others in the workplace. VitalCore Health Strategies is an equal opportunity employer and is committed to creating and maintaining an inclusive workplace in which all employees have an opportunity to participate and contribute to the success of the business and are valued for their skills, experience, and unique perspectives. Full-Time Day Shift

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