Job Description

POSITION SUMMARY RESPONSIBILITIES

Serves as the primary point of contact for utilization management authorization requests received by telephone, fax, electronic submission, provider portal, or other designated intake channels. Performs intake, screening, documentation, tracking, routing, and status communication activities related to utilization management requests. Verifies member eligibility and benefit information, enters authorization requests into designated systems, and ensures requests are routed timely to appropriate clinical reviewers. Provides administrative support to utilization management, care management, and other Population Health functions while maintaining compliance with NCQA, URAC, CMS, Texas Medicaid, HIPAA, and organizational requirements. Does not perform medical necessity reviews or make utilization management determinations. Ensures utilization management requests are processed timely and accurately in accordance with regulatory, contractual, accreditation, and organizational turnaround time requirements

EDUCATION/EXPERIENCE

A high school diploma or equivalent is required. Associate degree, business coursework, healthcare administration coursework, or equivalent experience is preferred. Minimum three (3) years of customer service, healthcare operations, health plan operations, call center, utilization management, prior authorization, claims, or care management support experience preferred. Experience using electronic health records, authorization systems, and managed care technology platforms preferred Working knowledge of medical terminology, managed care operations, utilization management processes, prior authorization workflows, customer service and call center standards, Medicare and Medicaid programs, and HIPAA requirements is preferred