[Remote] Utilization Management Services Representative

Note: The job is a remote job and is open to candidates in USA. Univera Healthcare is focused on providing quality healthcare services, and they are seeking a Utilization Management Services Representative to support UM workflows. The role involves providing administrative support and customer service, facilitating communication with internal and external customers, and managing authorization requests for various healthcare services.ResponsibilitiesFacilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environmentResponds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policiesPerform triage for UM ServicesServes as the primary contact for providers regarding authorization requestsContacts members and providers concerning regulatory requirements relating to Department of Health (DOH) notifications and other regulatory requirements such as the National Committee for Quality Assurance (NCQA) guidelinesProvides timely response to all research inquiries from other departments and assures the response is thorough, accurate, and within regulatory timeframesProcesses fax requests from the designated fax and system queuesConsistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefsMaintains high regard for member privacy in accordance with the corporate privacy policies and proceduresRegular and reliable attendance is expected and requiredPerforms other functions as assigned by managementAssists and performs tasks associated with project and departmental managementBackup Team Leads by assisting with questions when neededWork on assigned offline projectsProvides, prepares, and assists with preliminary support to multiple levels of providers and or members (as well as others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers, members, pharmacies, pharmacists, and support staffProvide one-on-one support, coaching, and training to UM Services RepsCollaborates with other key departments (Claims, Customer Service, related care management units) to ensure end-to-end process for authorizations, telephonic notifications, and/or care management referrals is accurate and completeAssists Team Leads with assigned tasks when necessary (including but not limited to authorizations, claims, care management referrals, monitoring and controlling inventory levels/call queues, timeliness, reporting)Meet departmental requirements for Facets UM Services workflows and PEGAResolves escalated customer questions and complex concernsAssists Medical Directors with scheduling Fair HearingsAssists with coordinating Grievance and Appeals requestsAssist with all Blue Card Claims escalationsAssist management with the review and creation of desk level procedures, acting as a subject matter expert for UM ServicesSkillsHigh School Diploma or GEDExperience with using a desktop computer in a professional environment, preferably with Microsoft Office ProductsStrong analytical and problem-solving skillsStrong written and verbal communication skills and ability to work within a teamDemonstrated organizational skills to manage multiple projects and prioritiesSelf-motivated and able to work independently, as well as on intra- and inter-departmental teams where needed2 years' experience working with managed care or healthcare industryAbility to apply in-depth knowledge of complex rules, such as those of the authorization process, regulatory processes/time frames, care management systems and processes, departmental policies and procedures, product lines, and contract benefitsAdvanced skills working between multiple programs and applications simultaneouslyDemonstrates willingness to develop collaborative solutions to achieve a better end-to-end processDemonstrates proficiency in basic navigation and utilization of department specific applicationsDemonstrates role-specific competencies as it pertains to their work unit on a consistent basisActive demonstration of broad knowledge base and positive work habits as evidenced by ability to train new staff, take on new challenges, flexibility in work assignments, and participation in meetings and projects as assigned4 years' experience working with managed care or healthcare industryDemonstrates a thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff and other areas within the company with related inquiriesDemonstrates operational knowledge of FACETS application and workflow processesAbility to resolve/respond to customer inquiries across multiple plans with limited assistanceAbility to collaborate within the organization when issues arise with limited assistanceAbility to identify potential systemic issues and report as necessary without supervisor assistanceAbility to work prolonged periods sitting at a workstation and working on a computerAbility to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a timeAbility to work in a home office for continuous periods of time for business continuityAbility to travel across the Health Plan service region for meetings and/or trainings as neededManual dexterity including fine finger motion requiredRepetitive motion requiredThe ability to hear, understand and speak clearly while using a phone, with or without a headsetCall center experience preferred, not requiredBenefitsParticipation in group health and/or dental insuranceRetirement planWellness programPaid time away from workPaid holidaysCompany OverviewUnivera Healthcare is a non-profit health plan that provides health services for New Yorkers. It was founded in undefined, and is headquartered in Buffalo, New York, USA, with a workforce of 201-500 employees. Its website is https://www.univerahealthcare.com.



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