Utilization Management Specialist

2 weeks ago

Philippines Netmark Business Services Full time $60,000 - $80,000 per year
Netmark Business Services specializes in healthplan IT solutions, offering a comprehensive suite of services designed to enhance efficiency and improve digital presence for health plans and Third-Party Administrators (TPAs). Key Services: Digital Experiences: Transforming traditional healthplan processes into seamless, user-friendly mobile experiences, including mobile health platforms and AI-powered services. Software Implementations: Expertise in configuring, implementing and optimizing leading adjudication platforms, including detailed requirement analysis, complex configurations, and seamless migrations. Data-Driven Solutions: Turning data into actionable insights with advanced analytics and automation solutions, creating powerful visualizations and real-time dashboards for smarter decision-making. Healthcare Solutions: Enhancing healthcare operations with a comprehensive suite of innovative solutions, from AI-driven claims processing, Utilization management to program integrity,payment accuracy….optimizing every aspect of managed care. Company Overview: With over two decades of experience, Netmark has evolved from paper-based operations to AI-driven automation, leading transformations that move health plans to the AI age. The company operates on a hybrid work model to optimize efficiency, reduce costs, and ensure seamless operations, investing significantly in training and technology to empower health plans and providers. Contact Information: Phone: Email: Address: 300 E Business Way, Suite 200, Cincinnati, OH 45241 Netmark's commitment to tailored strategies, innovative solutions, and comprehensive support positions them as a trusted partner in the healthcare industry, dedicated to driving efficiency, compliance, and impactful outcomes for their clients.

The Role

About The Role

We are seeking a dedicated Utilization Management Specialist to join our team as a Remote UM specialist. In this role, you will be responsible for reviewing and analyzing clinical information to determine the medical necessity and appropriateness of healthcare services, ensuring compliance with established guidelines and policies. Your expertise will contribute to optimizing patient care and resource utilization.

Key Responsibilities
  • Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health.
  • Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services.
  • Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization.
  • Maintain accurate and organized documentation of all utilization management activities.
  • Participate in quality improvement initiatives and assist in developing clinical guidelines.
  • Monitor and report on utilization trends to management, identifying areas for improvement.

Ideal Profile

Qualifications
  • Bachelor's Degree in Nursing (BSc Nursing) or equivalent.
  • Minimum of 2 years of clinical experience in a hospital or healthcare setting.
  • Active and unrestricted Registered Nurse (RN) license in the United States.
  • Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual).
  • Proficient in medical terminology, anatomy, and physiology.
  • Strong analytical and problem-solving skills.
  • Excellent communication skills, both written and verbal.
  • Proficient in Microsoft Office applications.

Preferred Qualifications
  • Experience with Medicaid, Medicare, and Managed Care programs.
  • Previous experience in utilization review or case management.
  • Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus.

What's on Offer?
  • Fantastic work culture

  • Real Estate Sales Specialist

    2 weeks ago

    Philippines Citiside Property Management Full time $40,000 - $60,000 per year

    We're looking for a dedicated Real Estate Sales Specialist to manage the entire sales process from start to finish. This role is ideal for someone with solid real estate experience who can build strong client relationships and contribute to achieving sales targets. You'll be responsible for nurturing leads, guiding clients through the sales journey,...

  • Associate Software Support Specialist, ERP Pro 10 Utilities

    23 hours ago

    , , Philippines Tyler Technologies, Inc. Full time

    Associate Software Support Specialist, ERP Pro 10 Utilities Do you possess a passion for people and technological affinity? Are you looking for a challenging career with significant growth potential? Join the Tyler Technologies team! We are looking for tech-savvy problem solvers to provide consultative support in an entry-level software support role. Support...

  • Hubspot Specialist

    2 weeks ago

    Philippines APRILMAE BARCELONA-ABRENILLA MANAGEMENT CONSULTANCY SERVICES Full time ₱283 per year

    Legacy Virtual is looking for a HubSpot Specialist (Expert Level)PERMANENT WORK-FROM-HOME JOBWork remotely?: YesJob role: HubSpot Specialist (Expert Level)Company: Legacy VirtualIndustry: Digital MarketingWork Hours and Schedule: US Business HoursWork Duration: Part-time, 20 hours per week with potential for full timeRate or Salary range: $5 per...

  • Oracle Utilities Application Developer – With Sign-On Bonus

    23 hours ago

    , , Philippines RIA Advisory LLC. Full time

    Job Title Oracle Utilities Application Developer – With Sign-On Bonus Qualification: Bachelor’s Degree in Computer Science or equivalent Location: Philippines/Hybrid Technical Know-How: Core JAVA/ J2EE (Collections/JDBC/Hibernate, Servlets, SOAP or REST, JUnit, Multithreading), SQL / RDBMS, JavaScript Job Description: Work on JAVA/J2EE based Oracle...

  • Hiring: Massive Hiring Clinical Nurse Specialist

    2 weeks ago

    Philippines Tippy Dos Santos Mourns Mother Full time $30,000 - $50,000 per year

    Job Title: Massive Hiring Clinical Nurse Specialist Company: Metacom Solutions, Inc. Job Description: Work Permanently From Home Metacom is hiring Clinical Nurse Specialists (USRN) Join us as Utilization Review Nurses. Responsibilities include reviewing patient cases and ensuring proper utilization of healthcare resources. Qualifications: At least 1 year of...

  • Workforce Management Specialist

    18 hours ago

    , Pampanga, Philippines Tata Consultancy Services Full time

    Overview JOB SUMMARY: Scheduling specialist is a critical role holding responsibilities to support and manage the scheduling activities for the contact center staff. Scheduling specialist must ensure the agent schedules are prepared in accordance with the local labor rules and regulations while aligning them closely to the Intraday staffing requirements...

  • Sales Support Specialist

    24 hours ago

    , , Philippines Clean Energy Associates Full time

    Reporting directly to the Senior Sales Support Specialist, the primary duties will be the following: Acknowledgment of Business Development requests at . Ensure Project Intake Form (PIF) is properly filled out by Business Development. Create ID # in the Proposal ID tracker for all. About the company Clean Energy Associates (CEA) is a North American-owned...

  • Senior Manager, Pharmacovigilance

    2 weeks ago

    Philippines PPD Latin America Full time $60,000 - $80,000 per year

    Location Remote, Philippines Job Id R Are you experienced in clinical safety and data management? Join a dynamic team where you'll coordinate safety data reviews, identify trends, and resolve issues. Bring your 2+ years of relevant experience, strong problem-solving skills, and attention to detail to ensure high-quality project implementation in a...

  • Senior Engineer, Water Utilities

    18 hours ago

    , Metro Manila, Philippines Aurecon Full time

    Join to apply for the Senior Engineer, Water Utilities role at Aurecon At Aurecon we see the future through a different lens. Innovation, eminence and digital are at the heart of everything we do. What will you do? As our new Senior Water Engineer, you’ll be a vital part of the team who are tackling and managing challenging water projects across a...

  • Client Success Specialist

    1 week ago

    Philippines Atticus Solutions Full time $104,000 - $130,878 per year

    The Client Success Specialist is responsible for ensuring customer success by managing and optimizing client relationships post-sale. This role focuses on making sure that clients fully understand and utilize the companys services to meet their business objectives. The Client Success Specialist proactively addresses client needs, resolves complex issues, and...