Utilization Management Representative (I, II, or Sr.)
Responsible for non-clinical tasks including performing outreach to members to connect them with a nurse for program enrollment and engagement, working faxes and calling facilities to request clinical. Primary duties may include, but are not limited:
A strong ability to work independently as well in small teams while contributing in a supportive way to the larger team. Handling incoming calls accurately and in a positive way, routing them to the correct team as needed.Determining contract and program benefit eligibility as part of the outreach process.Referring calls and cases requiring clinical review to a Nurse reviewer as needed through performing outreach, working faxes, account pool callouts and incoming calls.Responsible for accurate and complete documentation of work in all appropriate systems.Must have excellent communication skills as well as an ability to pay close attention to detail, to multitask and to prioritize work effectively.Responds to telephone and written inquiries from clients, providers and in-house departments including task, letter, predetermination and AMR creation.Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner. Responsible for tracking production, running and working reports, actively participating in the team plan daily.Some examples of assorted projects include mentoring, creating job aids and assorted administrative tasks.
Qualifications
Requires High school diploma/GED1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background. Medical terminology training and experience in medical or insurance field preferred.
Responsible for non-clinical tasks including performing outreach to members to connect them with a nurse for program enrollment and engagement, working faxes and calling facilities to request clinical. Primary duties may include, but are not limited:
A strong ability to work independently as well in small teams while contributing in a supportive way to the larger team. Handling incoming calls accurately and in a positive way, routing them to the correct team as needed.Determining contract and program benefit eligibility as part of the outreach process.Referring calls and cases requiring clinical review to a Nurse reviewer as needed through performing outreach, working faxes, account pool callouts and incoming calls.Responsible for accurate and complete documentation of work in all appropriate systems.Must have excellent communication skills as well as an ability to pay close attention to detail, to multitask and to prioritize work effectively.Responds to telephone and written inquiries from clients, providers and in-house departments including task, letter, predetermination and AMR creation.Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner. Responsible for tracking production, running and working reports, actively participating in the team plan daily.Some examples of assorted projects include mentoring, creating job aids and assorted administrative tasks.
Qualifications
Requires High school diploma/GED1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background. Medical terminology training and experience in medical or insurance field preferred.