Utilization Management Support Specialist I - Remote US

ATTENTION MILITARY AFFILIATED JOB SEEKERS - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps.

 

Must have all of the following:
Understands health plan benefit structures.
Familiarity with psychiatric/medical terminology.
Strong verbal and written communications skills.
Possesses initiative and interpersonal effectiveness
Is personally accountable and adaptable.
Is effective at building strong interpersonal work relationships.
Work experience in healthcare required



Assists in the physician advisor process for cases sent for peer-to-peer review. Supports the scheduling of reviews, communicating the results and completing the required verbal and written correspondence.

    Provides non-clinical support to workflows involving utilization management.
    Performs outreach contact to providers and written notification to providers and members for initial determinations.
    Consults with internal departments to ensure cases meet guidelines.
    Researches cases referred to peer review and contacts the facility to schedule a physician-to-physician review.
    Documents task completion in applicable internal systems.
    Maintains the integrity of the company relationship with stakeholders by researching and responding to provider needs.
    Identifies risk situations and escalates to supervisor as appropriate.
    Achieves and maintains department and individual performance standards.
    Prepares administrative, approval and clinical denial letters as assigned.
    Reviews completed denial letters to ensure accuracy, template use and within the appropriate grade level.
    Troubleshoots issues noted on letters by coordinating with team members and physicians to ensure clear and accurate letters. Completes data validation for data entry on letters (address, dates, and other fields as applicable).
    Assumes responsibility for self-development, career progression and ongoing training to ensure accuracy of work.
    Assists in the mentoring and training of new UM Support Specialists.
    Coordinates and manages distribution of correspondence and materials to enrollees and providers.
    Participates in operational activities, including data collection, tracking, and analysis.
Additional Qualifications/Responsibilities
Understands health plan benefit structures.
Familiarity with psychiatric/medical terminology.
Strong verbal and written communications skills.
Possesses initiative and interpersonal effectiveness
Is personally accountable and adaptable.
Is effective at building strong interpersonal work relationships.

General Job Information

Title
Utilization Management Support Specialist I

Grade
19

Work Experience - Required
Healthcare

Work Experience - Preferred

Education - Required

Education - Preferred
Associate

License and Certifications - Required

License and Certifications - Preferred

Salary Range

Salary Minimum:
$37,725

Salary Maximum:
$56,595