Utilization Review Specialist

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Harvard Pilgrim Healthcare
December 6, 2018
Boston, Massachusetts
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Job Description - Utilization Review Specialist (180000C3)

Job Description

Job Title

: Utilization Review Specialist

Job Number:


Job Posting

: Dec 4, 2018, 11:04:53 AM



Are you interested in becoming part of a dynamic team that is looking to innovate and improve?

Would you like to work for a company that has been rated by the BBJ (15+yrs) as one of the best places to work?

Do you want to be part of a company that is committed to giving back to the community?

Harvard Pilgrim Health Care is currently seeking highly motivated individuals to join our organization as a Utilization Review Specialist.  The Utilization Review Specialist is responsible for reviewing and coordinating requests for authorization of services with Utilization Management staff.  Responsible for applying state mandated guidelines and operational guidelines based upon benefit eligibility.


  • Complies with and ensures compliance with all regulatory and accreditation agency standards.
  • Acts as a liaison for a variety of internal and external staff to facilitate a timely case review.  Educates internal staff and external providers about the company’s utilization management guidelines for services
  • Receives incoming requests for services; coordinates receipt of patient medical records and related clinical information.
  • Researches and reviews Out-of-Plan requests, interacting with Physician Advisors (PA), Primary Care Providers (PCP), Specialists and company Associate Medical Director as appropriate.
  • Processes Precertification Approval and Denial letters, reviewing for appropriateness of free text, clinical rationales based on information provided by the Physician Advisors and Associate Medical Directors and correct data in accordance with HPHC/NCQA/HIPAA/CMS standards.
  • Perform out-of-the-box thinking, collaborate with others, and make a difference every day!
  • Other duties and projects as assigned.





  • Associates Degree or related experience and 3 – 5 years of experience or equivalent combination of education and experience required.
  • Sound knowledge of medical terminology Understanding and experience working in a Managed Care Organization.
  • Must possess basic computer and communication skills, the ability to work as part of a team yet be self-directed to manage caseload.
  • Sound problem solving skills and the ability to prioritize workload to accommodate fluctuating volumes.
  • Resilient, collaborative, flexible, innovative.



  • Work-Life-Flexibility
  • Paid volunteer time off (up to 3 days annually)
  • Open Time Off (include for exempt positions only)
  • Annual Mini-Grant of $500 donated to a non-profit organization of the employee’s choice
  • Educational Reimbursement

Working Environment

Location varies between company offices and home office.  Travel to various work locations within the company’s service area.


The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification.  They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.


Primary Location

: United States of America-Massachusetts-Quincy




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Harvard Pilgrim supports individuals in reaching their full potential by supporting equal employment opportunities and an environment that actively values diversity. Harvard Pilgrim complies with all applicable laws concerning hiring and employment practices and is firmly committed to fostering and maintaining a workplace free from discrimination. We pledge to hire, train, and promote our employees without regard to race, religion, gender, gender identity, genetic information, age, national origin, sexual orientation, disability, veteran status, or any other category protected by applicable law.

Harvard Pilgrim endeavors to make www.harvardpilgrim.org accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact HR Customer Service at 617-509-7500/TTY (800) 637-8257.

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