Utilization Management Representative II

About the role

The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions. This position is based at 4751 Hamilton Wolf Rd, Ste 101, San Antonio - TX.

Responsibilities

• 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.

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 Experiences

• Knowledge of health plans, including familiarity with prior authorization and precertification process; knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.
• Previous experience of prior -authorization management is strongly preferred.
• Prior experience working in a high-volume environment is preferred.

Benefits

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. Certain contracts require a Master's degree.

Pay

Market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Schedule

This position will work an 8-hour shift, Monday through Friday. Candidate should have availability from 8:00 am to 6:00 pm (CDT). Additional hours, including weekends or holidays, may be required based on operational needs.

Qualifications

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.