Utilization Management Representative Ii

Description:

• The Utilization Management Representative II is responsible for conducting service coordination functions for a defined caseload of individuals
  
  How will you make an impact
   
  • Managing incoming calls
  • Determine contract and benefit eligibility; creates authorizations for LTSS members.
  • Obtains intake (demographic) information from LTSS providers.
  • Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.
  • Processes incoming requests, collection of information needed for review from providers.
  • Verifies benefits and/or eligibility information.
  • May act as a liaison between LTSS and internal departments.
  • Responds to telephone and written inquiries from providers and in-house departments.
  • Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost effective and efficient utilization of long term services and supports.
  • May also serve as to mentor, subject matter expert or preceptor for new staff, assisting the formal training of associates, and may be involved in process improvement initiatives.
     
  Minimum Requirements
   
  • Requires HS diploma or equivalent and a minimum of 2 years customer service experience in healthcare related setting and medical terminology training; or any combination of education and experience which would provide an equivalent background.
     
  Preferred Skills, Capabilities And Qualifications
   
  • 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.
  • Previous experience working in a social work setting preferred.
  • BA/BS degree is preferred in the field of health care.
  • Specific education, years and type of experience may be required based upon state law and contract requirements.
  • Travel to worksite and other locations when necessary.