Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies, state, and federal guidelines. Additionally, will maintain Single Case Agreement (SCA) processes and document appropriate information in several applications and be responsible for responding to inquiries from Members and Providers to clarify benefits, provide member education and member referrals to support Health Management Services in various data fulfillment, reporting, monitoring and tracking of services as needed.
Essential Duties and Responsibilities
- Coordination, authorization, fulfillment, reporting, monitoring and tracking of services and single case agreements
- Establish working relationships with referral sources, providers, community agencies and vendors to proactively coordinate access to services.
- Maintains and supports documentation, logs and data entry to monitor activity and/or outcomes related to care coordination services in an accurate and timely manner.
- Assist with associates out in the field with pre-certification and authorization requests as well as member encounters utilizing the appropriate systems and resources.
- Communicate with the Manger of Utilization Management or the Director of Health Management Services all efforts to assure that Medicaid and Medicare rates are negotiated for the single case agreements for the services rendered.
- Completes initial welcome telephonic screening and makes outreach calls to members as needed.
- Ensure compliance with all department timelines including telephone service standards and turn-around times.
- Two-year Associate's degree or equivalent experience, preferred.
- High School Diploma or equivalent is required
- 1 year + experience in a managed health care company, preferred
- Data entry experience in a clinical setting using medical terminology, CPT and ICD-9/10 coding, required
Specific knowledge, skills and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Duties require little or no exertion of physical effort.