Utilization Management Specialist

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: +1 859-300-6213 Email: [email protected] 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.
  
  

• 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.
  
  

• 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.
  
  

• Fantastic work culture