Utilization Management & Quality Review Specialist

University of California - Los Angeles Health
United States, California, Los Angeles
Oct 31, 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