Magellan Health · 1 day ago

Utilization Management Support Specialist I

United States

Full-time

Remote

Entry Level

$38K/yr - $57K/yr

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Responsibilities

Assists in the physician advisor process for cases sent for peer-to-peer review.

Supports the scheduling of reviews, communicating the results and completing the required verbal and written correspondence.

Provides non-clinical support to workflows involving utilization management.

Performs outreach contact to providers and written notification to providers and members for initial determinations.

Consults with internal departments to ensure cases meet guidelines.

Researches cases referred to peer review and contacts the facility to schedule a physician-to-physician review.

Documents task completion in applicable internal systems.

Maintains the integrity of the company relationship with stakeholders by researching and responding to provider needs.

Identifies risk situations and escalates to supervisor as appropriate.

Achieves and maintains department and individual performance standards.

Prepares administrative, approval and clinical denial letters as assigned.

Reviews completed denial letters to ensure accuracy, template use and within the appropriate grade level.

Troubleshoots issues noted on letters by coordinating with team members and physicians to ensure clear and accurate letters.

Completes data validation for data entry on letters (address, dates, and other fields as applicable).

Assumes responsibility for self-development, career progression and ongoing training to ensure accuracy of work.

Assists in the mentoring and training of new UM Support Specialists.

Coordinates and manages distribution of correspondence and materials to enrollees and providers.

Participates in operational activities, including data collection, tracking, and analysis.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Utilization ManagementHealthcare experiencePsychiatric terminologyMedical terminologyData validationInterpersonal effectivenessMentoring