Utilization Management Representative I/II/III

Company: Anthem, Inc.
Location: Winston Salem
Posted on: November 18, 2021

Job Description:

Description: Description SHIFT: Day Job SCHEDULE: Full-time Your Talent. Our Vision. At Anthem, Inc., 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 at one of America's leading health care companies and a Fortune Top 50 Company. Location: Needs to be located within 50 miles of an Anthem USA office This position is posted as a job family and the selected candidate will be placed into the job level commensurate with their experience Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. Primary duties may include, 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. Utilization Management Representative II is 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. Utilization Management Representative III is 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. Qualifications Utilization Management Representative I * 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. * For URAC accredited areas the following applies: Associate is expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Utilization Management Representative II * 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. * For URAC accredited areas the following applies: Associate is expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Utilization Management Representative III * Requires a HS diploma or GED and a minimum of 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 required. * For URAC accredited areas the following applies: Associate is 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. We offer a range of 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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For--, is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

Keywords: Anthem, Inc., Winston-Salem , Utilization Management Representative I/II/III, Executive , Winston Salem, North Carolina