Utilization Management Rep I - Healthsun Ps18453

Anthem, Inc. Coconut Grove , FL 33133

Posted 5 months ago

Your Talent. Our Vision. At HealthSun, 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 at one of America's leading health benefits companies and a Fortune Top 50 Company.

We have a Utilization Management Representative I that will be responsible for coordinating cases for precertification and prior authorization review. Must be able to successfully perform all the duties of the Utilization Management Representative.

Primary duties may include, but are not limited:

  • Managing incoming calls.

  • Monitor and distribute all incoming and outgoing faxes.

  • Process referral requests (following the pre-cert department process & protocol): Outpatient Services, in-office procedures and or visits, DME, Home Health, Infusion services, enter authorization for hospital admissions and or any service that may require Pre-Certification.

  • Utilize established criteria and knowledge of benefits and group contracts to determine coverage of requested services.

  • Refers cases requiring clinical review to a Nurse reviewer/Medical Director.

  • Responsible for the identification and data entry of referral requests into the UM system in accordance the Health Plan's EOC.

  • Responds to telephone and written inquiries from clients, providers and in-house departments.

  • 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.

  • Assist in other plan areas as necessary with clerical and data entry support

  • Requires High school diploma/GED;

  • Minimum of 2-4 years' experience in the healthcare field (in a physician office and or managed care setting).

  • Knowledge with Medicare within the managed care industry. Specifically the Organization Determination process.

  • Knowledge of ICD-10, HCPCS, CPT coding and CMS guidelines.

  • Computer knowledge: word & excel

  • Strong decision-making and organizational skills.

  • Well-developed technical skills.

  • Excellent verbal communication and interpersonal skills.

  • Must be able to work with limited supervision.

  • Willingness and ability to function independently and as a team member.

  • Working Knowledge of medical terminology.

  • Follow HIPPA guidelines.

  • Be able to type at least 45 wpm.

  • Intermediate computer skills.

  • Excellent organizational skills.

  • Ability to handle multiple functions and prioritize appropriately.

  • Ability to meet strict deadlines.

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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Utilization Management Rep I - Healthsun Ps18453

Anthem, Inc.