Healthcare Management - Healthcare Utilization Management
Management Level - New Associate
Years of Experience:
0 to 1 years
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What would you do?
The Healthcare Operations vertical helps our clients drive breakthrough growth by combining deep healthcare delivery experience and subject matter expertise with analytics, automation, artificial intelligence and innovative talent. We help payers, providers and government agencies increase provider, member and group satisfaction, improve health outcomes and reduce costs.
You will be a part of the Healthcare Management team which is responsible for the administration of hospitals, outpatient clinics, hospices, and other healthcare facilities. This includes day to day operations, department activities, medical and health services, budgeting and rating, research and education, policies and procedures, quality assurance, patient services, and public relations
You will be responsible for Healthcare Utilization Management which is a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case by case assessments of the appropriateness of care prior to its provision.
What are we looking for?
• Healthcare Utilization Management
• Adaptable and flexible
• Ability to work well in a team
• Commitment to quality
• Written and verbal communication
• Health Insurance Portability & Accountability Act (HIPAA)
Roles and Responsibilities
• In this role you are required to solve routine problems, largely through precedent and referral to general guidelines
• Your primary interaction is within your own team and your direct supervisor
• In this role you will be given detailed instructions on all tasks
• The decisions that you make impact your own work and are closely supervised
• You will be an individual contributor as a part of a team with a predetermined, narrow scope of work
• Please note that this role may require you to work in rotational shifts
• Manages incoming or outgoing telephone calls, eReviews, and/or faxes, including triage, opening of cases and data entry into client system.
• Determines contract; verifies eligibility and benefits.
• Conducts a thorough provider radius search in client system and follows up with provider on referrals given.
• Checks benefits for facility-based treatment.
• Obtains intake (demographic) information from caller, eReview and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization.
• Performs data entry of contact into client systems and routes as appropriate
• Match fax/clinical records with appropriate case.
• Consolidate inputs for approval.
• Generate needed letters.
• Assign cases/activities and work within client’s system to facilitate workflow and productivity goals.
• Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and “nurse ready”.
• Tasks cases accurately to the correct queue.