Utilization Management Support Specialist I

Magellan Health

2d

About The Position

Assists in the physician advisor process for cases sent for peer-to-peer review. Supports the scheduling of reviews, communicating the results and completing the required verbal and written correspondence. Provides non-clinical support to workflows involving utilization management. Performs outreach contact to providers and written notification to providers and members for initial determinations. Consults with internal departments to ensure cases meet guidelines. Researches cases referred to peer review and contacts the facility to schedule a physician-to-physician review. Documents task completion in applicable internal systems. Maintains the integrity of the company relationship with stakeholders by researching and responding to provider needs. Identifies risk situations and escalates to supervisor as appropriate. Achieves and maintains department and individual performance standards. Prepares administrative, approval and clinical denial letters as assigned. Reviews completed denial letters to ensure accuracy, template use and within the appropriate grade level. Troubleshoots issues noted on letters by coordinating with team members and physicians to ensure clear and accurate letters. Completes data validation for data entry on letters (address, dates, and other fields as applicable). Assumes responsibility for self-development, career progression and ongoing training to ensure accuracy of work. Assists in the mentoring and training of new UM Support Specialists. Coordinates and manages distribution of correspondence and materials to enrollees and providers. Participates in operational activities, including data collection, tracking, and analysis. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Requirements

• Understands health plan benefit structures.
• Familiarity with psychiatric/medical terminology.
• Strong verbal and written communications skills.
• Possesses initiative and interpersonal effectiveness
• Is personally accountable and adaptable.
• Is effective at building strong interpersonal work relationships.

Responsibilities

• Assists in the physician advisor process for cases sent for peer-to-peer review.
• Supports the scheduling of reviews, communicating the results and completing the required verbal and written correspondence.
• Provides non-clinical support to workflows involving utilization management.
• Performs outreach contact to providers and written notification to providers and members for initial determinations.
• Consults with internal departments to ensure cases meet guidelines.
• Researches cases referred to peer review and contacts the facility to schedule a physician-to-physician review.
• Documents task completion in applicable internal systems.
• Maintains the integrity of the company relationship with stakeholders by researching and responding to provider needs.
• Identifies risk situations and escalates to supervisor as appropriate.
• Achieves and maintains department and individual performance standards.
• Prepares administrative, approval and clinical denial letters as assigned.
• Reviews completed denial letters to ensure accuracy, template use and within the appropriate grade level.
• Troubleshoots issues noted on letters by coordinating with team members and physicians to ensure clear and accurate letters.
• Completes data validation for data entry on letters (address, dates, and other fields as applicable).
• Assumes responsibility for self-development, career progression and ongoing training to ensure accuracy of work.
• Assists in the mentoring and training of new UM Support Specialists.
• Coordinates and manages distribution of correspondence and materials to enrollees and providers.
• Participates in operational activities, including data collection, tracking, and analysis.

Benefits

• Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree