Member Utilization Representative
Newbury Park , CA 91320
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Member Utilization Representative - Health Plan
Thousand Oaks, CA
This is a Full-Time, Benefits Available, CONTRACTopportunity,expected to last 2 months, or longer!
Utilization Representative (Inbound Calls)
Member Utilization Representative Background:
- The role of the Member Utilization Representative is to assist Utilization Review nurses by screening Prior Authorization and coordination of specialized services requests, including a broad range of requests for inpatient, outpatient and ancillary services.
- The purpose of the Prior-Authorization, or Pre-Certification, process is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to Prior Authorization requests.
- The Prior Authorizations Specialist is essential to ensuring that prior authorization requests are completed in a timely fashion to meet contractual requirements.
- Maintains current knowledge of network resources for linking member and provider needs.
- Authorizes certain specified services, under the supervision of the manager and according to established departmental guidelines.
- Per standard workflows, forwards specified requests to the clinician for review and processing.
- Additionally, the Specialist answers inbound calls from providers and other departments and redirects, as needed.
- Requires an education level of at least a high school diploma or GED.
- 1-2 years customer service experience.
- Strongly prefer around 1 year experience in a call center settingor phone support role.
- Any healthcare experience is a plus.
- Ability to multi-task duties as well as the ability to understand multiple products and multiple levels of benefits within each product.
- Computer skills to include Microsoft Word, Excel and basic data entry, including the ability to learn new and complex computer system applications.
- Must test at a minimum of 35 wpm typing with a high level of accuracy.
- Basic computer literacy (MS Office) and typing skills are necessary.