Title: Utilization Management Representative I
Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Utilization Management Representative I will be responsible for coordinating cases for precertification and prior authorization review.
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.
• 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.
Minimum Requirements
• HS diploma or GED
• Minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
Preferred Qualifications
• 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.
Location: Louisville, KY (+4 others)
Posted: Sept. 1, 2024, 7:07 a.m.
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