Crox Media Private Limited

Compensation

Full Description

Job Summary • The Utilization Management Specialist (UMS) will play a pivotal role in supporting the Utilization Management (UM) team. This multifaceted position will focus on both clinical and administrative functions within the UM department, ensuring seamless operations and effective management of utilization processes. Qualifications • Preferred Education: Associate degree in related field • Preferred Experience: Case Management Assistant • Required Education: High school diploma or G.E.D. • Required Experience: Three years in a health Care setting or one year in Utilization Management or Case Management at a Medical Group, Acute Care Environment or health plan experience; Electronic Health Record (EHR) and Utilization Management applications, (e.g. EPIC, or 3M). Knowledge, Skills and Abilities • Excellent organizational and multitasking skills. • Proficient in Microsoft Office Suite (Word, Excel, Outlook) and other relevant software. • Effective communication skills, both verbal and written. • Ability to work autonomously and as a team member in a fast-paced, deadline-driven environment. • Ability to create and present PowerPoint presentations to large groups. • Knowledge of payor portals access and use, and insurances (Medicare, Medi-Cal, Commercial). • Able to receive feedback from leadership. • Adheres to AHS code of conduct. • Ability to pay attention to details. Physical Requirements and Work Environment • The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Payer Liaison: • Serve as the primary point of contact for all insurance-related inquiries and interactions. Facilitate clear and accurate communication between the UM department and payers, addressing issues, sending clinical information, and ensuring timely processing and receipt of Inpatient authorizations and/or denials. Fax Management: • Check all UM fax folders daily to ensure timely receipt and sending of documents. • Ensure that clinical documentation is faxed to and received by all payers to support inpatient admissions and/or denials. • Maintain accurate records of all fax communications. Optum Portal Management: • Check Optum Portal frequently throughout the day to ensure that all determinations are addressed and uploaded to the EPIC charts. Authorization Management: • Obtain initial and concurrent inpatient authorizations from insurance companies for all inpatient admissions. • Track the status of authorization requests and follow up with insurance companies, as needed. • Confirm patient’s insurance coverage and benefits, as requested. • Accurately document all communication with insurance companies in EPIC. • Maintain detailed records of authorization requests, approvals and inpatient denials. • Update UR team on the status of authorizations, as required. • Maintains current database of payor contact information. Data Entry and Reporting: • Perform accurate data entry into the EHR, ensuring data integrity. Multitasking and Prioritization: • Manage multiple tasks and responsibilities effectively in a fast-paced, ever-changing environment. • Prioritize tasks to meet deadlines and support the needs of the department. Administrative Support: • Provide comprehensive administrative assistance to the Utilization Review (UR) team. • Assist with other duties, as assigned. • Participate in new staff onboarding, as needed. Job Type: Contract Pay: $28.00 per hour Expected hours: 40 per week Experience: • tilization Management or Case Management at a Medical Group: 3 years (Required) • Epic: 3 years (Required) • 3M: 3 years (Preferred) • Electronic Health Record (EHR) : 3 years (Required) • Healthcare/Hospital/Medical Office: 3 years (Required) Work Location: Remote