Utilization Management Representative IILocation : This position will work remotely. The ideal candidate will live within 50 miles of one of the following PulsePoint locations, St. Louis, MO; Atlanta, GA; Chicago, IL; Indianapolis, IN; Louisville, KY;The Utilization Management Representative II is 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.
Determining contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests.
Obtains intake information from the caller.
Conducts a thorough radius search in Provider Finder and follows up with the provider on referrals given. Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.
Processes incoming requests, collects 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 a 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.
Requires a minimum of 2 years of customer service experience in healthcare-related settings and medical terminology training or any combination of education and experience that would provide an equivalent background.
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.