Overview
The Utilization Management Member Service Representative is responsible for the timely authorization and renewal of services for members. Works in collaboration with members of Utilization management department, care management department and external vendors in order to ensure that authorizations for services are completed timely, correctly and comprehensively. This position is critical in the Delivery and provision of covered services and the correct payment of claims for those services.
Responsibilities
- Accurate processing of Authorizations for new and existing member Services including but not limited to:
- Eligibility Verification
- Benefit Verification
- Review of prior authorization activity
- Appropriate certification dates
- Processing of service requests forms and telephone notes within regulatory time frames
- Ensures timely notification and coordination with external service vendors for all authorized services.
- Responsible for the accurate and detailed documentation of communications and activities related to service requests and authorizations in the electronic medical record.
- Review and timely renewal of existing service authorizations as per process and policy
- Data entry into the Utilization Departmental Dashboard and tracking
- Maintains Professional Communication regarding authorized member services to external vendors, as well as the Archcare Community Life Utilization Management, Care Management, Re-assessment and Quality departments.
- Creates regulatory required member communication documents such as extension letters and Initial Adverse Determination letters.
- Reports any barrier/delay in authorization process to the Utilization Management Director/ Associate Director
- Timely modification/adjustment of authorization based on vendor communication/member episode
- Telephonic and e-mail communication with vendors to coordinate service delivery
- Obtains assistance and direction from the Utilization Management Director/ Associate Director for complex and difficult service requests/authorizations.
Qualifications
Education
- High School Diploma or GED
- Associates Preferred
Experience
- 2 Years of Managed Long Term Care Experience
- 2 Years of Utilization Management
- ICD-10 Coding