Responsible for the execution of the non-clinical aspects of the Utilization Management and/or Case Management process. Ensure information is appropriately entered in the system to effectively execute member care plans, originate authorizations, request clinical information, perform case research, and essentially execute all behind the scenes “mechanics” of a case. Work seamlessly with the Care Specialists and Care Managers (RN’s) to ensure everything that a participant needs to tend to their health is arranged and taken care of.
- Work collaboratively, as a critical component of the Medical Management team, to facilitate all clerical and administrative processes and activities.
- Perform accurate and timely intake and data entry for all UM authorization requests and referrals for all lines of business, upon receipt of inbound utilization management requests, via call, fax and web portal, in accordance with departmental policy and regulatory requirements.
- Triage cases and assign receipts to appropriate teams.
- Perform other related projects and duties as assigned.
- Respond to inquiries from providers, facilities and members.
- Initiate completion of member and provider correspondence and verbal outreach according to departmental guidelines.
- Enter and maintain documentation in the medical management workflow tool meeting defined timeframes and performance standards.
- Communicate with members and providers regarding member’s authorization status, as required.
- Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities as required by clinical staff.
- Support communication and coordination with delegated entities, as necessary.
- Actively participate in assigned committees and projects.
- High School Diploma required
- Bachelor’s in related field preferred
- At least 1-2 years of previous call center or data entry experience in a utilization or care management environment within managed care.
- Additional years of experience/certifications/training may be considered in lieu of educational requirements.
- Strong oral, written and interpersonal communication skills required.
- Ability to work both independently and collaboratively with others.
- Previous system user experience in a highly automated environment required with strong PC skills required.
- Knowledge of medical terminology, ICD-10 and CPT coding preferred.
- Ability to prioritize multiple tasks.
- Required to work weekends and holiday as necessary.