Utilization Management Services Rep

Job Description

This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment.

This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment.

• Facilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environment.
• Responds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies.
• Perform triage for UM Services.
• Serves as the primary contact for providers regarding authorization requests.
• Contacts members and providers concerning regulatory requirements relating to Department of Health (DOH) notifications and other regulatory requirements such as the National Committee for Quality Assurance (NCQA) guidelines.
• Provides timely response to all research inquiries from other departments and assures the response is thorough, accurate, and within regulatory time frames.
• Processes fax requests from the designated fax and system queues.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

• Assists and performs tasks associated with project and departmental management.
• Backup Team Leads by assisting with questions when needed.
• Work on assigned offline projects.
• Provides, prepares, and assists with preliminary support to multiple levels of providers and or members (as well as others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers, members, pharmacies, pharmacists, and support staff.
• Provide one-on-one support, coaching, and training to UM Services Reps.
• Collaborates with other key departments (Claims, Customer Service, related care management units) to ensure end-to-end process for authorizations, telephonic notifications, and/or care management referrals is accurate and complete.

• Assists Team Leads with assigned tasks when necessary (including but not limited to authorizations, claims, care management referrals, monitoring and controlling inventory levels/call queues, timeliness, reporting).
• Meet departmental requirements for Facets UM Services workflows and PEGA.
• Resolves escalated customer questions and complex concerns.
• Assists Medical Directors with scheduling Fair Hearings.
• Assists with coordinating Grievance and Appeals requests.
• Assist with all Blue Card Claims escalations.
• Assist management with the review and creation of desk level procedures, acting as a subject matter expert for UM Services.

NOTE
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We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

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