Utilization Management Rep II (US)

will be responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

How you will make an impact:

• Managing incoming calls or incoming post services claims work

Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests

• Obtains intake (demographic) information from caller

Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given

• Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care
• Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization
• Verifies benefits and/or eligibility information
• May act as liaison between Medical Management and internal departments\
• Responds to telephone and written inquiries from clients, providers and in-house departments
• Conducts clinical screening process

Minimum Requirements:

Requires HS diploma or equivalent and a minimum of 2 years customer service experience in healthcare related setting and medical terminology training; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills Certain contracts require a Master's degree