Job Description

The Utilization Management Specialist implements, maintains and executes procedures and processes by which Optum performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to referral authorization questions. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

Primary Responsibilities:
Initiate Referral Authorizations
• Acquires and maintain a working knowledge of Optum contracted health plans agreements and related insurance products
• Provides administrative and enrollment support for team to meet Company goals
• Gathers information from relevant sources for processing referrals and authorization requests
• Submits authorization & referral requests to healthplan via avenue of insurance requirement.

Including but not limited to website, phone, & fax
• Track authorization status inquires for timely response
• Maintains strong understanding of and educate our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Utilization Management and authorizations.
• Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Utilization Management process and requirements
• Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements
• Documents patient information in the electronic health record following standard work guidelines
• Coordinates with Clinical teammates and health plans to identify patients with Utilization
Management needs
• Provides member services to all patient group
• Answers referral and authorization inquiries from health plans, our clinical areas, patients and outside Optum Physician office/facilities
• Assists in the development and implementation of job specific policy and procedures
• Assists in the collection of information for member and/or provider appeals of denied requests
• Identifies areas for potential improvement of patient satisfaction

Shift is Monday-Thursday from 8-4:30pm and Friday from 8-12pm

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