The Clinical Operations department is seeking an Utilization Management Specialist to join their team full time working out of Seattle, WA. Remote option available.
The Utilization Management Specialist functions as an integral member of the team and is responsible for implementing, maintaining, and executing procedures and processes by which OCN performs its referral and authorization process. This position responds to inquiries from members, staff and physicians pertaining to managed care benefits and referral authorization status. In addition, this position sends out confirming copies of referrals, authorizations, or denial letters as required by health plan guidelines. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent, and retrospective referrals.
The Utilization Management Specialist is responsible for and not limited to:
- Reviews and processes all managed care member referrals and clinical service requests by following established protocols, guidelines, and medical necessity
- Interfaces with necessary entities to support decisions within time restraints of established protocols
- Performs verification of eligibility on each referral request of managed care
- Verifies benefits for services requested using health plan guidelines
- Keeps current on health plan benefits and structure and researches unusual requests with health plan when necessary to determine benefits and coverage
- Directly contacts health plans when necessary to verify benefits and eligibility when information is not available
- Enters all requests and inquiries from medical staff and members into Authorization System following established protocols and timelines
- Follows up on all requests for information and documentation
- Refer to appropriate staff for higher level of review when indicated by request
- Maintains statistical tracking and monitoring of assigned referrals at all levels of review for instant retrieval
- Routinely produces written communication as needed to uphold effective departmental communication policies and procedures
- Responds to inquiries from external agencies regarding the necessary steps of the medical referral and authorization process
- Gathers information from relevant sources for processing referrals and authorizing services to Managed Care members
- Provides copies of authorizations as necessary to initiate treatment of Managed Care members
- Accurately documents the services that are approved by UM process
- Assists in the development and implementation of job specific policy and procedures
- Assists in the development of educational information for providers regarding Utilization Review Protocols
- Assists in conducting review of retrospective referrals and claims to verify all authorized services were performed as specified
Preferred Experience and Credentials:
Education: High School Diploma or equivalent
- 2 years working experience with managed care products; including Senior, Commercial and Medicaid plans
- 2 years working experience with multiple health care delivery systems
- InterQual or Milliman medical necessity criteria experience preferred
- Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance
- Employees are required to screen for symptoms using an approved symptom screener prior to entering the work site each day, in order to keep our work sites safe.
- Employees must comply with any state and local masking orders. In addition, when in a worksite building, employees are expected to wear a mask in areas where physical distancing cannot be attained.
40 hours per week, Monday-Friday 8 am - 5 pm PST. Rotating Sunday afternoon/evening shift.
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