Utilization Mgmt Coord

Job Description: Olympic Health Management Utilization Management Coordinator

Summary: Provides medical, utilization management and claims processing to evaluate the necessity, appropriateness and efficiency of medical services, procedures and facilities concerning the use of non-network facilities for Medicare SELECT Supplement policies. Provides technical expertise, coordination and administrative support to Medical Case Manager and UR Nurse.

Duties and Responsibilities:

Claims Adjudication:
1. Research, investigate, document findings and formulate professional objective decisions for claims adjudication.

2. Research and adjudicate claims pended on specialized adjudication screens.

3. Update Network Hospital Services lists.

4. Assist with reporting to client concerning non-network usage.

5. Communicate with policyholders, health care providers and other professionals by managing incoming and outgoing data.

6. Compose customized correspondence, merge documents, create templates, spreadsheets, charts and graphs, and generate reports.

7. Other duties as assigned.

Pre-Authorization Requests and Reconsideration Requests:
1. Provide training and consistent support to Customer Service Representatives and Claims personnel. Assist Customer Service with inquiries.

2. Obtain additional information from health care providers, network facilities, policyholders and/or other parties.

3. Work with healthcare providers and policyholders to provide individual research into insurer, policy, plan, and network facility for the most appropriate outcome.

4. Effectively and professionally communicate findings, outcomes, trends and decisions to appropriate parties through written correspondence or via telephone.

Large Dollar Amount Claims:
1. Research plan, policy, claim and policyholder history to verify appropriateness of dollar amount.

2. Contact appropriate parties when dollar amount exceeds pre-defined threshold. Notify supervisor if communication with or approval from Client is required.

3. Communicate findings to appropriate internal parties, efficiently and professionally

Case Management:
1. Assist Medical Case Manager in identifying, researching and monitoring appropriate cases.

2. Assist Medical Case Manager with compiling and generating internal and external reports, letters and other documents.

Knowledge, Skills, and Abilities:
* Solid understanding of Medicare SELECT Supplement policies, network restrictions and exceptions, and network providers
* Well-developed analytical, organizational and time management skills
* Strong verbal and written communication skills
* Computer skills, including MS Word and Excel
* Maintain a sense of professionalism at all times.
* Maintain confidentiality of member, physician and employee information
* Ability to work independently and in a team setting
* Ability to train staff
* Ability to work well under various stressful and time sensitive situations
* Individual initiative to take on various tasks
* Willingness to support and educate co-workers, fostering a team-work atmosphere.
* Courteous and professional telephone manner
* Working knowledge of Medicare rules and regulations effecting health services to Medicare enrollees
* Working knowledge of medical terminology and anatomy and physiology
* Ability to understand and follow oral and written instructions

Education and Experience:
* High School Diploma or equivalent
* Education or work experience involving medical terminology, anatomy & physiology, medical disease & pathology and/or healthcare training
* Working knowledge of medical claims and claim coding
* Administrative experience including intermediate computer knowledge and skills.

Desired:
* Bachelors Degree or completion of an AA or certificate program in a healthcare related field
* Experience in, or understanding of, hospitals, healthcare, and/or insurance industry
* Working knowledge of Medicare rules and regulations effecting health services to Medicare enrollees

Essential Functions:
* Manual dexterity in hands to do extensive keyboarding
* Requires the ability to sit for extended periods of time
* Requires the ability to speak and hear to exchange information with customers on the telephone

HOW TO APPLY

1. Apply online by locating ? Click here to apply via the Aon Career Opportunity Portal? at the bottom of this job description.

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