• Screens information received and refers members to the appropriate provider and/or contacts the provider directly for members.
• Facilitates the authorization process for requests that do not require clinical criteria application or judgment.
• Provides relevant information to members and assists them in resolving Plan related problems when Member Services personnel are not available.
• Acts as a resource to staff for questions related to the prior authorization process.
• Refers unresolved prior authorization process questions to the Lead Intake Specialist.
• Assists the Lead Intake Specialist in identifying, planning and implementing staff training programs.
• Identifies and reports member and provider educational opportunities to the Lead Intake Specialist.
• Accurately answers questions regarding Plan benefits and Utilization Management requirements for members and providers.
• Makes appropriate inquiries to determine potential coordination of benefits and advises appropriate provider and claims staff of same.
• Supports Utilization Management nurses with data entry.
• Performs other duties as assigned.
• Adheres to Select Health and KMHP policies and procedures.
• Supports and carries out the Select Health and Mercy Mission & Values.
• Customer service experience and interpersonal skills on phone and in-person
• Proficient PC Skills in a Windows based environment including word processing, spread sheets and working in database programs.
• Working knowledge of plan benefits and services
• Proven ability to keep accurate and timely records and documentation according to established processes
Zolon Tech, Inc. (ZTI) is a fast-growing, 8(a) certified business providing Information Technology solutions and services to Federal and commercial clients. ZTI is CMMI Level 3, ITIL, and ISO 20000 certified and is a leader in the IT industry. Headquartered in Herndon- VA.
Role: Utilization Management Tech
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