Utilization Management Assistant

About Us

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children, and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

Responsibilities

• Serves as support to Medical Management Intake Department.
• Primarily responsible for processing initial incoming faxes or phone requests into the intake department.
• Gathers demographic and benefit data and documents it in the appropriate system, following documented policy and procedures.
• Adheres to time frames and turnaround times, as evidenced by results of inter-rater reliability reviews.
• Routes and evaluates all calls and faxes to refer and assign as necessary to other staff.
• Performs data entry of authorization information into systems and/or faxes information to originating physicians, facilities, or specialists.
• Implements nuances of product line and regulatory requirements in the processing of all authorization requests, including notification requirements.
• Responsible for confirming eligibility for requested authorizations and for requesting membership identification numbers for newborns.
• Educates providers on authorization requirements, processes, and policy and procedures of the Health Plan.
• Receives transfer calls from member services relating to authorization issues, questions, or capabilities of service providers.
• Assists and collaborates with all medical management staff, as well as other health plan staff, e.g., Claims Department, Network Development.
• Provides customer service and education for all incoming calls regarding provider and/or product information.

Requirements

• High School Diploma or GED required.
• Some college coursework preferred.
• 2 years of managed care experience, preferably in a medical management department, claims, or member services.
• Experience in a healthcare or insurance environment.