Location: Within 50 miles or a 1 hr commute of Miami or Tampa Florida
Hours: Monday - Friday, 8:30 am - 5:30 pm EST, possible weekend coverage as needed
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.
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.
Certain contracts require a Master's degree.
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.
Previous experience working with authorizations (related to Autism) is strongly preferred.
