Utilization Management Support Specialist

SKYGEN•United States,

3d•$22 - $31•Remote

About The Position

This role involves performing regular audits of authorization case work using internal practices and policies. The specialist will provide administrative setup and technical support for authorization processing to ensure service level agreements (SLAs) are met, in compliance with contractual and regulatory requirements. A key responsibility is to assist in determining the root cause of quality issues and processing errors, and to recommend and implement solutions to prevent future errors.

Requirements

High school diploma or equivalent
2 plus years of job related experience
Excellent Computer literacy including strong proficiency in Microsoft Office
Ability to remain organized with multiple interruptions
Excellent ability to organize work appropriately ensuring deadlines are met
Excellent communication skills including both internal and external customers
High attention to detail and accuracy
Strong problem solving skills to allow for the correct diagnosis of a problem along with potential solutions for resolution.
Some knowledge of/prior use of SQL
SQL experience is required.
Candidates should be highly detail-oriented and able to work independently with minimal supervision.

Nice To Haves

Associates Degree/2 year degree or Bachelor’s degree
Two or more years in a quality role
Experience with healthcare terms
Knowledge of dental and vision claims payment and billing processes
Knowledge of general practices for appeals, complaints, and grievances handling
Knowledge of federal and state regulations as it pertains to health care compliance
Holds Enterprise System Certification(s)

Responsibilities

Perform daily audits of authorization turnaround times to ensure compliance, coordinating completion when necessary.
Perform monthly (more frequent when needed) audits of authorizations worked by Authorization Support Representatives for quality and accuracy.
Communicate with management and other internal staff on audit findings and provide any appropriate process change recommendations.
Work with the UM Analyst to resolve any processing issues leading to audit concerns and recommend and implement appropriate solutions/controls, including support of SKYGEN’s Internal Priority Quality Initiative (IPQI) processes and post implementation monitoring.
Provide technical assistance to the clinical and administrative team, including system setup, attachment vendor setup, and day-to-day troubleshooting.
Aid in configuration and auditing of authorization setup in the Enterprise System.
Create and run SQL scripts to monitor SLA adherence and aid in authorization processing.
Maintain current knowledge of Utilization Management/Authorization policies and procedures, URAC and NCQA standards.