Utilization Management Rep I (PHL)

Position Title:

Utilization Management Rep I (PHL)

Shift:

Job Description:

Responsible for coordinating cases for precertification and prior authorization review. Primary duties may include, but are not limited: Manages 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. Requires High school diploma/GED; 1 year of customer service or call-center experience in healthcare related setting; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background. Medical terminology training and experience in medical or insurance field preferred. 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.