Job Details

Summary of Position

Responsible for the execution of the non-clinical aspects of the Utilization Management process. Ensure information is appropriately entered in the system to effectively execute member care plans, originate authorizations, request clinical information, perform case research, and execute all behind the scenes desk-level procedures of a case. Work seamlessly with other interdisciplinary teams to ensure members' needs are met. Provide confidential administrative support and assistance to the department in all aspects of daily program operations.

Responsibilities:

• Work with the Medical Management team to facilitate all clerical and administrative processes and activities.
• Perform accurate and timely intake and data entry for all UM authorization requests and referrals for all lines of business, upon receipt of inbound utilization management requests, via call, fax and web portal, in accordance with departmental policy and regulatory requirements.
• Triage cases and assign receipts to appropriate teams; respond to inquiries from providers, facilities and members.
• Initiate member and provider correspondence and verbal outreach according to departmental guidelines.
• Enter and maintain documentation in the medical management workflow tool, meeting defined timeframes and performance standards.
• Provide phone management for both incoming and outgoing calls.
• Communicate with members and providers as required.
• Perform other related projects and duties as assigned.
• Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities as required by clinical staff.
• Support communication and coordination with delegated entities, as necessary.
• Actively participate in assigned committees and projects.

• High School Diploma required
• Associates degree or Bachelors' degree in related field preferred
• 1 - 2+ years of client-facing or data entry experience in a health care environment
• Additional experience/certifications/training may be considered in lieu of educational requirements
• Strong communication skills (verbal, written and interpersonal)
• Ability to work both independently and collaboratively with others
• Previous system user experience in a highly electronic environment
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.)
• Knowledge of medical terminology and medical payment
• Ability to prioritize multiple tasks
• Ability and willingness to work weekends and holidays as necessary