What are the responsibilities and job description for the Utilization Management Specialist position at Group Health Cooperative of Eau Claire?
Position Purpose
This position is responsible for promoting appropriate, effective and efficient use of health care resources via prior authorization review. The scope of this position includes using criteria sets and policy and procedures to review clinical care and treatment plans and out of network referrals to determine appropriateness.
Essential Position Functions:
This position is responsible for promoting appropriate, effective and efficient use of health care resources via prior authorization review. The scope of this position includes using criteria sets and policy and procedures to review clinical care and treatment plans and out of network referrals to determine appropriateness.
Essential Position Functions:
- Applies clinical experience, health plan benefit structure, health management policies and procedures, and claims payment knowledge to authorization reviews.
- Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
- Gathers relevant clinical data through multiple sources to complete authorization reviews.
- Identifies opportunities to advance the health and well-being of the member.
- Identifies and refers members to case management when appropriate.
- Prioritizes and organizes work to complete prior authorization reviews in a timely manner.
- Maintains outstanding level of service at all points of contact.
- Collaborates and maintains positive, effective working relationships with all internal and external stakeholders.
- Communicates in a professional and timely manner.
- Displays empathy toward members.
- Maintains accurate and concise case records with timely documentation.
- Maintains confidentiality of member and case information by following corporate privacy policies.
Minimum Requirements of the Position
- Certification in a medical field desirable;
- A minimum of one year experience in a clinical or managed care setting;
- Ability to learn and adapt;
- Proficient in the use of Microsoft Office Suite.
- Candidates with telephone customer service or call center experience are preferred.
Group Health Cooperative of Eau Claire complies with applicable Federal civil rights laws and does not discriminate, exclude or treat candidates less favorably on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex (including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender
identity; and sex stereotypes).
The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.
This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.
identity; and sex stereotypes).
The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.
This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.
