Canton, OH, United States
Work At Home, Customer Service, Call Center
Utilization Management Representative I-II-III - Remote - PS24377
Location: Albany, New York, United States
Requisition #: PS24377
Post Date: 4 hours ago
Your Talent. Our Vision . At Empire Blue Cross Blue Shield , a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and 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.
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Utilization Management Representative I, II, III
We may fill this position at Level I, II, or III – level will be based on your skills and experience and will be determined by the hiring manager.
Location: This is a remote, work-from-home opportunity
Work Hours: Monday through Friday, 8:00am - 4:30pm EST or 8:30am - 5:00pm EST
Responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.
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 coordinating cases for precertification and prior authorization review.
This level is expected to be able to perform all of the duties of the Utilization Management Rep II in addition to the following primary duties.
Primary duties may include, but are not limited to:
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.
Requires High School diploma or equivalent;
Level I: 1 year of customer service or call-center experience in a healthcare related setting;
Level II: 2 years of customer service or call-center experience in a healthcare related setting;
Level III: 3 years of experience in customer service experience in healthcare related setting
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.
Requires great customer service skills/experience
Requires great typing skills
Microsoft Office (Word, Excel, Outlook)
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.
Website : http://www.antheminc.com
The company was formed when WellPoint Health Networks Inc. and Anthem, Inc. merged in 2004 to become the nation's leading health benefits company. The parent company originally assumed the WellPoint, Inc. name at the time of the merger. In December 2014, WellPoint, Inc. changed its corporate name to Anthem, Inc. The Anthem brand is built on a foundation of trust – it’s the name consumers are most familiar with as a trusted health care partner through our affiliated health plans. Anthem, Inc. is one of the largest health benefits companies in the United States. Through its affiliated health plans, Anthem companies deliver a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, Anthem, Inc. is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states.