Utilization Management Specialist

The Utilization Management (UM) Specialist is responsible to collect and monitor routine to complex health care services data and verify benefit/eligibility in an effort to improve those services using established policies, procedures and guidelines.  The UM Specialist receives, reviews, verifies and processes requests for a variety of medical services. The UM Specialist will work closely with the Utilization Management (UM) Nurses on any case that requires the expertise of a nurse and requires medical judgment.

The UM Specialist is accountable to investigate member history and eligibility as appropriate, contact Case Managers and nurses to gather further information, support the health plan needs to be cost effective and quality conscious, identify and report issues that may result in a grievance to ensure appropriate awareness, serve as a mentor to other team members, assist in training of staff and assist in the development of policies and procedures as requested.

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Essential Functions

  • Consistently exhibits behavior and communication skills that demonstrate Tandigm’s commitment to superior customer service, including care and concern for each and every internal and external customer.
  • Collaborates with UM Nurses to provide best-practice care coordination and support with the highest level of professionalism and accountability to patients, families, and caregivers.
  • Requests clinical information from the medical provider, as appropriate.
  • Responsible to answers/monitors all UM calls and the caller to the appropriate teammate and assures coverage of phone lines at all times.
  • Maintains a courteous, professional attitude when working with facility staff, providers and their staff, the health plan and co-workers.
  • Reviews medical requests with the RN Case Manager, UM Manager and/or Medical Director and other team members as needed and appropriate prior to making any uncertain decisions.
  • Acts as a resource to other coordinators, staff, and providers, resolves issues in a timely and efficient manner.
  • Provides timely and accurate documentation that is compliant with all established standards.
  • Responsible for documenting ICD-10 and CPT coding and levels of care to accurately reflect care and services provided for claim adjudication.
  • Participate in internal audit reporting as necessary.
  • Actively participates in team meetings.
  • Uses, protects, and discloses Tandigm patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
  • Perform additional duties as assigned.

Education

  • Minimum: High school diploma, G.E.D. or equivalent.
  • Preferred: Associate’s or Bachelor’s Degree.

Experience

Minimum:  3 years of professional experience in a customer-oriented setting.

Preferred: 4-6 years of professional experience in a physician practice; hospital; or health plan.

Knowledge, Skills and Abilities

  • The self-motivated individual who takes on this rewarding role will have a history of success in project accountability and customer responsiveness; is a team player yet comfortable working autonomously; and is detail-oriented, accurate, and thorough.
  • Customer-service oriented; responsive and respectful to colleagues, clients, patients, and providers.
  • Excellent communication skills; ability to represent the organization with skill and confidence.
  • Demonstrates superior interpersonal skills; the ability to engage and motivate patients, physicians, and service providers telephonically.
  • Organized, detailed, accurate.
  • Self-motivated and proactive; responds to requests in a timely and efficient manner.
  • Collaborative and resourceful; functions successfully in a team environment as well as independently.
  • Computer literate with proficiency in Microsoft Office suite of programs.
  • Proficient with web-based search engines and software applications, office hardware (phones, fax machines, etc.)
  • Ability to type at least 45 wpm.
  • Knowledge and familiarity with medical terminology.
  • Working knowledge of HMO/managed care/health plans.

Physical Requirements in Accordance with ADA

  • Carrying/Lifting:              Occasional/0-20 lbs
  • Standing:                         Occasional/Up to 3 hours per day
  • Sitting:                             Constant/Up to 8 hours per day
  • Walking:                          Occasional/Up to 1 hour per day
  • Repetitive Motion:          Keyboard activity, telephone use, writing
  • Visual Acuity:                  Ability to view computer monitor and read newsprint with or                                        without corrective lenses
  • Environmental Exposure: None
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