Inpatient Utilization Management Specialist

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Inpatient Utilization Management Specialist is responsible for screening inpatient admissions requests in the medical care management program. Adheres to policies and procedures in order to meet performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines. Per standard workflows, forwards specified requests to the clinician for review and processing. Answers calls from providers and other departments and redirects, as needed.

Our Investment in You:

• Competitive salaries
• Full-time remote work
• Excellent benefits

Schedule: Tuesday - Saturday 8:30 - 5:00

Key Functions/Responsibilities:

• Processes Utilization Management Department reports as assigned, handles and follows up on claims related questions
• Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full workload
• Works with providers and key departments to promote an understanding of inpatient admissions requirements and processes
• Requests clinical information and discharge dates per workflow
• Coordinates resolution of escalated provider inquiries
• Informs provider of authorization decision per department procedure
• Answers provider calls and follows up with the information necessary to complete the caller’s request within assigned timeframe
• Prioritizes and processes incoming requests, including authorizing specified inpatient admissions requests, as outlined in departmental policies, procedures, and workflow guidelines
• Participates in team operational activities, including but not limited to primary responsibilities for triage function, department voicemail coverage
• Refers requests that require clinical judgment to Inpatient Utilization Clinician
• Other duties as assigned
• Supports Inpatient admission Clinicians
• Maintains general understanding of applicable sections of member handbooks, evidence of coverage, and BMHCP extranet

Qualifications:

Education Required:

• Associate’s degree in Healthcare, Nursing, Social Work or a related area or equivalent relevant work experience is required

Experience Required:

• Experience with Health Plan Utilization
• 2 years of office experience, specifically in either a high volume data entry office, customer service call center, or health care office administration department
• Knowledge of Healthcare - MassHealth rules and regulations, preferred

Preferred/Desirable:

• Prior customer service experience
• Bilingual skills, fluency in Spanish
• Experience with CCMS, JIVA, FACETS or other healthcare database
• Experience with Health Plan Utilization / Claims departments

Competencies, Skills, and Attributes:

• Ability to prioritize work when processing referrals and authorization requests per guidelines and within specific Turn Around Timeframes
• Competency with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications
• Strong oral, listening, interviewing, interpersonal, written, and verbal communication skills; the ability to interact and work successfully with internal and external colleagues
• Ability to effectively prioritize and manage multiple tasks in a fast-paced environment
• Ability to process high volumes of requests at department defined accuracy rate
• Strong customer service skills and diplomacy skills
• Bi-lingual preferred

Required Skills:

• Strong customer service skills
• Ability to prioritize and manage multiple tasks in fast-paced environment
• Strong oral, listening, interviewing, written and verbal communication skills
• Ability to prioritize work when processing events, admission, authorization requests within TAT
• Competency with MS Office, Outlook, Word, CCMS, Advanced TIFF Software, Facets
• Ability to process high volumes of requests at department defined accuracy rate

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

• WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.

Required Skills
Required Experience