The Utilization Management Tech functions under the direction of the Supervisor to coordinate, generate and track both incoming and outgoing correspondence, faxes and authorizations related to prospective, concurrent and post service review functions. Interacts with facilities, vendors, providers, and other staff to facilitate receipt of information, and /or records for prompt review and response. Compensation plans for physicians, licensed nurse reviewers, staff, and consultants who conduct medical management do not contain incentives, directly or indirectly, that encourage barriers to care and service in making determinations
1. Supports the daily operations of Utilization Management, Concurrent Review, Retrospective Review and Prior Authorization teams through interaction with staff, facilities, vendors and providers.
2. Maintains a current knowledge base of Utilization Management processes and timelines.
3. Processes all incoming and outgoing correspondence/faxes in accordance with required standards and within respective timeliness guidelines. Refers as appropriate to clinical team members for review as defined by workflow.
4. Performs in a call center environment appropriately processing or triaging calls from providers.
5. Creates, updates maintains and/or closes authorizations for services as assigned within process guidelines.
6. Clerical responsibilities such as processing urgent scanning/mailing requests, document/record archival, document/record retrieval, interact with the Department of Public Welfare, database data entry, database reporting and the ordering of supplies.
7. Demonstrates a professional and courteous manner when communicating with others with the ability to clearly and accurately state the agreed upon resolutions.
8. Participates collaboratively with business partners to obtain, track, and report information as needed for corporate and/or regulatory reporting.
9. Adheres to AmeriHealth Caritas Family of Companies Policies and Procedures, Process Standards, and Standard Operating Procedures. Maintains current knowledge of AHC member benefits, rights and responsibilities.
10. Maintains current knowledge base in AHC systems and programs to appropriately document case activity.
11. Demonstrates flexibility with ability to set priorities within established deadlines and timeframes.
12. Demonstrates independence and initiative with completing assignments and follow-up.
13. Participates in Quality Reviews and Timeliness studies and achieves performance results at or above thresholds established by management.
14. Complies with AmeriHealth Caritas Family of Companies and HIPAA confidentiality requirements and ensures protection of member personal health information.
15. Supports and carries out the plan's Mission and Values.
16. Performs other related duties and projects as assigned within the assigned timeframes.
Education and Training:
High School Diploma or GED required.
Minimum 1 year general office and/or customer service experience required.
Work experience in healthcare setting required.
Knowledge of medical terminology required.
Licenses, Registrations or Certifications.
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