Utilization Management Representative I, II, or III

Utilization Management Representative I, II, or III

16 Dec 2024
California, Picorivera, 90660 Picorivera USA

Utilization Management Representative I, II, or III

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At Beacon Health Options, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.For more than 30 years, Beacon Health Options has changed the way people live with behavioral health conditions. Today, we are the undisputed leader in behavioral health management, serving 37 million people across all 50 states. At Beacon, our mission is to help people live their lives to the fullest potential. Beacon offers superior clinical mental health and substance use disorder management, a comprehensive employee assistance program, work/life support, specialty programs for autism and depression, and insightful analytics to improve the delivery of care.Position: Utilization Management Representative I, II, or III

Location: RemoteThis position may be filled as a Utilization Management Representative level I, II, or III - the hiring manager will determine the level based on the candidate's experience and background

The Utilization Management Representative is responsible for coordinating cases for precertification and prior authorization review. Primary duties may include, but are not limited to: 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.

Obtains intake (demographic) information from caller.

Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given.

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, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization.

Verifies benefits and/or eligibility information. May act as liaison between Medical Management and internal departments.

Responds to telephone and written inquiries from clients, providers and in-house departments. Conducts clinical screening process.

Responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set.

Assisting management by identifying areas of improvement and expressing a willingness to take on new projects as assigned.

Handling escalated and unresolved calls from less experienced team members; ensuring UM Reps are directed to the appropriate resources to resolve issues.

Ability to understand and explain specific workflow, processes, departmental priorities and guidelines.

May assist in new hire training to act as eventual proxy for Ops Expert.

Exemplifies behaviors embodied in the 5 Core Values.

Qualifications Education: High school diploma/GED required

Experience: 3 years of experience in customer service experience in healthcare related setting required; or any combination of education and experience which would provide an equivalent background

Knowledge, Skills, & Abilities:

Strong oral, written and interpersonal communication skills required

Strong problem-solving skills and analytical skills required

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.REQNUMBER: PS42838

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