Remote Utilization Management Rep I/II (Anthem) 51 views

Job Overview

  • State License (Select 'ANY' & Your State) Any

The Utilization Management Representative is responsible for coordinating cases for precertification and prior authorization review.

Primary duties may includes, but are not limited:

  • 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.
  • Refers cases requiring clinical review to a Nurse reviewer.
  • Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
  • Responds to telephone and written inquiries from clients, providers and in-house departments.
  • Conducts clinical screening process.
  • Authorizes initial set of sessions to provider.
  • Checks benefits for facility based treatment.
  • Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
  • Requires High school diploma/GED.
  • 1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background.
  • Medical terminology training and experience in medical or insurance field preferred.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Medical coding experience preferred.

 

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