• Utilization Management Specialist

    Location US-CA-Alameda
    Posted Date 1 week ago(3/13/2018 2:11 PM)
    Job ID
    # of Openings Remaining
    Experience (Years)
  • Overview

    The Utilization Management Specialist, under the direction and supervision of the Supervisor, Outpatient Utilization Management (UM), is responsible for triaging authorizations to claims adjudication process issues related to all authorization types. This position serves as the UM department’s subject matter expert on the authorizations to claims adjudication process.


    Principal responsibilities include:


    · Understand the inpatient and outpatient authorization rules and applicablity to claims adjudication.

    · Understand the claims system authorization to claims verificaton requirements and when possible, suggest solutions to improve the succesful claims adjudication rate.

    · Understand the Divison of Financial Responsibility (DoFR) between the Alliance and delegated medical groups as it relates to claims adjudication.

    · Trouble shoot authorizatons to claims issues from all referral sources and manually correct authorizations to ensure successful claims adjudication.

    · Monitor the Claims Operaton Database (COD) electronic claims queue and manually correct authorizations to ensure successful claims adjudication.

    · Serve as UM subject matter expert for claims troubleshooting, which may involve training other staff on authorizations to claims adjudication process.

    · Act as the liaison and initial point of contact for authorizations to claims adjudication issues between other internal departments including, but not limited to Provider Services, Claims, Applications and Configurations,  Compliance, etc. .

    · Participate in interdepartmental claims meetings as requested by management

    · Complete routine and ad-hoc reports as needed.

    · Meet authorization-to-claims adjudication triage load, productivity, and efficiency goals as set by management.

    · Complete other duties and special projects as assigned to support UM department processes and procedures, which may include authorization processing.





    · Manage the COD claims database; manually correct authorizations to facilitate accurate claims adjudication

    · Receive requests from other departments for manual corrections of authorizations to facilitate accurate claims adjudication

    · Thoroughly understand the inpatient and outpatient authorization rules, and the authorization-to-claims-adjudication process

    · Act as the initial point of contact for authorization-to-claims adjudication issues

    · Participate in internal claims meeting

    · On an as needed basis, assist the UM department with authorization processing

    · Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.





    · Constant and close visual work at desk or computer.

    · Constant sitting and working at desk.

    · Constant data entry using keyboard and/or mouse.

    · Constant use of telephone headset.

    · Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

    · Frequent lifting of folders and objects weighing between 0 and 30 lbs.

    · Frequent walking and standing.




    · Bachelor’s degree from an accredited college with a major in human services, psychology, or other relevant focus, or

    · AS/AA degree or two years of college with a minimum of one year experience making healthcare-related assessments and referrals, and/or experience in working with medical claims, or

    · In lieu of two years college education, a minimum of four (4 years) experience in prior authorizations, medical claims, or healthcare is required.




    · Minimum three years customer service experience in the health care field (preferably in a health plan setting) and a working knowledge of medical and insurance terminology required.

    · Minimum four years office experience in a medically related field (e.g., physician office, home health department, physical therapy office) required.




    · Proficient in medical terminology and CPT/HCPC, ICD9-CM, ICD10-CM, NDC codes.

    · Proficient in claims terminology such as CPT/HCPC and revenue codes

    · Excellent oral and written communications skills required.

    · Well organized and detail oriented.

    · Ability to handle multiple projects and balance competing priorities and short deadlines.

    · Demonstrated skills in problem resolution, independent thinker, and logical. 

    · Skilled proficiency in the use of computer software such as: Microsoft Access, Word, Excel, Outlook and PowerPoint.


    Pay Range:

    $28.25 - $48.73


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