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Utilization Management Representative I/II/III- Any Anthem location- PS15414

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Customer Service
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PS15414 Requisition #
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Your Talent. Our Vision. At Empire Blue Cross Blue Shield, a proud member of the Anthem, Inc. family of companies,  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.  

Utilization Management Representative I-III
This position will be filled at Level I, II, or III, which will be determined by the hiring manager, based on skills and experience. 

Level I
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.

Level II
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.

Level III
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. 
Requirements:
Level 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.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Level II
  • Requires High school diploma/GED; 
  • 2 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.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Level III
  • Requires a high school diploma/GED; 
  • 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.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

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