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Utilization Management Specialist Location: Mohan Cooperative, New Delhi Required Experience: 2 - 5 years Required Qualifications - Bachelors degree in any field - Experience with insurance providers, hospital administration, or managed care organizations is desirable Skills and Competencies: - Strong understanding of medical terminology, clinical practices, and healthcare regulations (e.g., CMS, HIPAA) - Proficiency in electronic medical records (EMRs) and utilization management software - Excellent communication, problem-solving, and decision-making abilities - Ability to analyze and interpret clinical data effectively - Knowledge of payer systems, billing processes, and managed care principles Work Environment: - May involve working closely with an insurance company / managed care setting - Work from office / US hours Perks and Perks: Best in industry Job description The Utilization Management (UM) Specialist ensures that healthcare services are delivered efficiently and meet quality standards while aligning with the organizations policies and regulatory requirements. The role involves reviewing medical records, coordinating care, and working with healthcare providers to manage patient treatment plans in a cost-effective manner. Responsibilities: - Utilization Review: - Evaluate the medical necessity, appropriateness, and efficiency of healthcare services. - Conduct pre-certification, concurrent, and retrospective reviews of care. - Ensure compliance with applicable guidelines and regulations. - Case Management Coordination: - Collaborate with healthcare providers, payers, and patients to coordinate care and services. - Advocate for optimal patient outcomes while managing resource utilization. - Documentation and Reporting: - Maintain accurate and up-to-date records of reviews, authorizations, and patient information. - Prepare reports on utilization trends, compliance issues, and quality metrics. - Policy Compliance: - Ensure adherence to organizational policies and external regulatory standards. - Stay updated on industry standards and best practices in utilization management. - Patient and Provider Communication: - Educate patients and providers about treatment options, insurance requirements, and care pathways. - Resolve disputes related to denied claims or coverage issues. - Candidates should be open to working in night shift - No cab .