Full Time - Regular
Roseburg, OR, US
The Utilization Specialist provides support to Umpqua Health Alliance (UHA) for the intake and processing of requests received by Medical Management in compliance with regulatory requirements.
ESSENTIAL JOB RESPONSIBILITIES
• Provide support for Utilization Review and Care Coordination as related to the prior authorization process.
• Manage the receipt of documentation through multiple sources on a daily basis including appeals, grievances and prior authorizations.
• Identify incoming documentation requests and redistribute to appropriate individual(s) for processing.
• Track and sort prior authorization requests and supporting information using current systems and processes.
• Support the timely notification of prior authorization determinations.
• Coordinate with other Utilization Review Specialists for daily management of department telephone coverage with individual login and availability.
• Research and respond to requests from internal and external customers regarding prior authorizations. Refer members and providers to other appropriate staff as necessary.
• Provide support to the Appeals & Grievances Coordinator as needed.
• Participate in department trainings, audits, and meetings as needed.
• Maintain a solid understanding of regulations and procedures.
• Review daily reports to monitor compliance.
• Maintain training documents and participate in updates for policies and procedures.
• Provide support for internal and external reporting.
• Comply with organization's internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
• Complexity of duties may vary based on the level of experience, education and qualifications of specialist.
• Other duties as assigned.
A medical background is preferred. The Specialist level is based on experience in the utilization review field.
• Level 1: High school diploma or equivalent. Some medical background preferred.
• Level 2: High school diploma or equivalent and a minimum of 2 years in utilization review or similar field.
• Level 3: Associates degree or a minimum of 3 years in utilization review or similar field.
• Level 4: Bachelor's degree or a minimum of 4 years of experience in health care professional setting in a med/surg, ambulatory care setting, clinical, behavioral health or social work setting required.
• Excellent interpersonal, written and oral communication skills.
• Prior experience in a customer service and/or clinical setting.
• Knowledge of medical terminology, procedure codes and diagnosis codes.
• Proficiency with MS Office applications such as; Office, Outlook and Excel.
• Proficiency with basic office equipment skills such as computer keyboarding, copy machines, multiline phone systems, etc.
• Ability to type at least 45 wpm with a high degree of accuracy.
• Ability to manage multiple priorities with attention to detail and follow-up.
• Ability to organize work and remain focused under stressful conditions with critical attention to detail for accuracy and timeliness.
• Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.
• Proficient understanding of medical terminology preferred.
• Ability to interact effectively and professionally with internal and internal customers.