Utilization Management Specialist

Group Health Cooperative•Altoona, WI

About The Position

This position is responsible for promoting appropriate, effective and efficient use of health care resources via prior authorization review. The scope of this position includes using criteria sets and policy and procedures to review clinical care and treatment plans and out of network referrals to determine appropriateness.

Requirements

Certification in a medical field desirable
A minimum of one year experience in a clinical or managed care setting
Ability to learn and adapt
Proficient in the use of Microsoft Office Suite

Nice To Haves

Candidates with telephone customer service or call center experience are preferred.

Responsibilities

Applies clinical experience, health plan benefit structure, health management policies and procedures, and claims payment knowledge to authorization reviews.
Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
Gathers relevant clinical data through multiple sources to complete authorization reviews.
Identifies opportunities to advance the health and well-being of the member.
Identifies and refers members to case management when appropriate.
Prioritizes and organizes work to complete prior authorization reviews in a timely manner.
Maintains outstanding level of service at all points of contact.
Collaborates and maintains positive, effective working relationships with all internal and external stakeholders.
Communicates in a professional and timely manner.
Displays empathy toward members.
Maintains accurate and concise case records with timely documentation.
Maintains confidentiality of member and case information by following corporate privacy policies.