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Insurance Utilization Reviewer Jobs in Maine (NOW HIRING)

Gianteagle

$16.50 - $20.50/hr

Ensure proper documentation for transmitting information to insurance companies, reviewing profiles for appropriate billing choices. * Alert pharmacists appropriately for drug utilization reviews ...

CVS Health

Case Manager, Registered Nurse

Sanford, ME · On-site

$54K - $155K/yr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... self-insured clients. * Application and/or interpretation of applicable criteria and clinical ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...

American Traveler

Travel Care Manager

Portland, ME · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

Travel RN - Case Management/Utilization Review - Case Management About American Traveler With over ... life insurance beginning day one of your assignment, generous 401(k) match, substantial housing ...

American Traveler

Travel RN Care Manager

Portland, ME · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

Travel RN - Case Management/Utilization Review - Case Management About American Traveler With over ... life insurance beginning day one of your assignment, generous 401(k) match, substantial housing ...

ChenMed

$118K - $168K/yr

... drug utilization review and patient counseling. The Incumbent will participate in Medication ... Knowledge of and experience with state and federal insurance programs. * Familiarity with ...

Berkley

Senior Casualty Claims Specialist

Westbrook, ME

$120K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Acadia Insurance is a regional property casualty insurer with offices throughout the Northeast. As ... Control file-related expenses through efficient utilization and monitoring of "outside" vendors.

Berkley

Senior Casualty Claims Specialist

Westbrook, ME · On-site

$120K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Company Details Acadia Insurance is a regional property casualty insurer with offices throughout ... Control file-related expenses through efficient utilization and monitoring of "outside" vendors.

Berkley

Senior Casualty Claims Specialist

Westbrook, ME

$120K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Company Details Acadia Insurance is a regional property casualty insurer with offices throughout ... Control file-related expenses through efficient utilization and monitoring of "outside" vendors.

Reliant Rehabilitation

Director of Rehabilitation

East Orland, ME · On-site

$72K - $77K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... paid life insurance • 401(k) with employer match • PTO Share and Buy-Back Programs • ... utilization review, quality assurance, resident care conferences, admissions, department head ...

Reliant Rehabilitation

Director of Rehabilitation

East Orland, ME · On-site

$72K - $77K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... paid life insurance • 401(k) with employer match • PTO Share and Buy-Back Programs • ... utilization review, quality assurance, resident care conferences, admissions, department head ...

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All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Maine

Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are popular job titles related to Insurance Utilization Reviewer jobs in Maine?

For Insurance Utilization Reviewer jobs in Maine, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in Maine look for?

The top searched job categories for Insurance Utilization Reviewer jobs in Maine are:

Insurance Utilization Reviewer jobs near you

Pharmacy Intern- South Side Giant Eagle

Gianteagle

On-site

$16.50 - $20.50/hr

Internship

Re-posted 7 days ago

Job description

Job Summary

As a Pharmacy Intern, you'll be a key part of our team. You'll bring your skills and expertise to Giant Eagle and contribute toward the creation of a service conscious pharmacy. You'll also build relationships with patients that exceed their expectations. And provide safe, accurate and efficient care and customer service in order to achieve the best patient, Team Member and company outcomes.

Job Description

  • Experience Required: 0 to 6 months
  • Education Desired: High school degree or equivalent and current enrollment in an ACPE-accredited pharmacy degree program
  • Certification or Licensing Required: Pharmacy; Active in-state Pharmacy Intern License
  • Lifting Requirement: Up to 25 pounds

Job Responsibilities

  • Maintain proper inventory levels by submitting on line order, adding and adjusting order points, order quantities and on-hand counts in the computer and assisting manager in preparation of physical inventories
  • Maintain a neat and clean work environment to ensure Company and government requirements are met.
  • File written prescriptions daily.
  • Assist Team Members with tasks to ensure department runs efficiently.
  • Review all appropriate service and business metrics and assist team on action plans to improve outcome.
  • Perform all regular duties of Pharmacy Technician.
  • Welcome and acknowledge patients at all pharmacy entry points immediately and with compassion and a smile.
  • Model excellent patient care by respecting, engaging and enthusiastically meeting or exceeding all patient needs including processing orders in person and by phone, directing patients to products and merchandise and referring appropriate questions concerning prescriptions and over the counter medicine to the pharmacist.
  • Finalize sales using cash register according to established procedures including the point of sale policies.
  • Perform all supporting duties to contribute to the safe and efficient dispensing of all patient medication and durable medical equipment by following all quality assurance policy and procedures including the selection and counting of medication.
  • Comply with all Giant Eagle and Pharmacy policies including HIPAA and pseudoephedrine regulations.
  • Enter patient personal data and insurance information.
  • Enter all prescription information including calculations, free form directions, medication and durable medical equipment specifications.
  • Ensure proper documentation for transmitting information to insurance companies, reviewing profiles for appropriate billing choices.
  • Alert pharmacists appropriately for drug utilization reviews, calling and resolving third party rejections and rebilling claims, entering and processing refills and adding patients to Refills on Time Program.
  • Process medical expense reports.
  • Assist in the execution of all company initiatives and programs.

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