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Utilization Management Representative I/II - Wallingford, CT or Indianapolis, IN - PS21696Location: New Haven, Connecticut, United StatesNewRequisition #: PS21696Your Talent. Our Vision. At Anthem, Inc. , it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.Utilization Management Representative I/IIThis position may be filled at Level I or Level II. This will be determined by the hiring manager based on your skills and experience.Location: Wallingford, CT or Indianapolis, IN
108 Leigus Road, Wallingford, CT 06492
220 Virginia Avenue, Indianapolis, IN 46204)
Work Hours: M-F 8:30am -5:30pm ESTLevel IResponsible for coordinating cases for precertification and prior authorization review.Primary duties may includes, but are not limited:
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.
Refers cases requiring clinical review to a Nurse reviewer.
Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
Responds to telephone and written inquiries from clients, providers and in-house departments.
Conducts clinical screening process. Authorizes initial set of sessions to provider.
Checks benefits for facility based treatment.
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.
Level IIResponsible for managing incoming calls, including triage, opening of cases and authorizing sessions.Primary duties may include, but are not limited to:
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.
Qualifications:Required:
Requires High school diploma/GED;
Level I: 1 year of customer service or call-center experience;
Level II: 2 years customer service experience in healthcare related setting;
Or, any combination of education and experience, which would provide an equivalent background.
Proficient analytical, written and oral communication skills
MS Office (Word, Excel, Outlook) proficiency
Computer skills and experience using instant messenger
Preferred:
Medical terminology training
Experience in medical or insurance field
Experience with ACMS, WGS, NASCO, MCW, and WDE Softphone programs
Experience in high-volume call center
Experience with Call Care Browser, OBIS, MCW, NASCO, and AUMI (Pega/ACMS). The associate will be expected, once trained, to be able to navigate multiple account types and their products and systems throughout the day.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.
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