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Utilization Management Processor Jobs

Healthcare - Case Management Processor
By Dice At United States
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Healthcare - Case Management Processor, Remote.
Provides support to the Case Management staff performing non clinical activities and supporting the management of the department.
Responsible for initial review and triage of Case Management tasks.
Screens members using Molina policies and processes assisting clinical Case Management staff as they identify appropriate medical services
Runs reports to assist in coordination of case management needs.
Utilization Management Technician Jobs
By AmeriHealth Caritas At , Remote
1 to 3 years Managed Care, Insurance, Call Center Experience
Minimum 1 year general office and/or customer service experience required.
Work experience in healthcare setting required.
Knowledge of medical terminology required
Your career starts now. We’re looking for the next generation of health care leaders.
Utilization Management Partner Jobs
By Lehigh Valley Health Network At , East Stroudsburg, 18301
3 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.
Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.
Knowledge of electronic medical records (EMR) and medical terminology.
Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.
Bilingual in English and Spanish.
Manager, Utilization Management Jobs
By Santa Clara Family Health Plan At , San Jose $122,529 - $189,920 a year
Understanding and/or experience with Utilization Management. (R)
Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws. Responsibilities include:
Minimum two years of experience in a supervisory capacity in a managed care setting. (R)
Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R)
Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.
Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
Utilization Management Clinician Jobs
By PacificSource Health Plans At , Salem
Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate.
Coordinate necessary resources to achieve member outcome goals and objectives.
Accurately document case notes and letters of explanation which may become part of legal records.
Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.
Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care.
Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.
Pharmacist Utilization Management - (Remote)
By Highmark Inc. At , From $67,500 a year
Oral & Written Communication Skills
Language Requirement (other than English)
Conduct research beyond medical policy review to make decisions on medication coverage requests.
1 - 3 years in Pharmacy
Problem Solving & Decision Making
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Utilization Management Coordinator Jobs
By Ascension At , Austin, 78736 From $22.28 an hour
Note: Required professional licensure/certification can be used in lieu of education OR experience, if applicable
2+ years of Health Insurance Utilization Management coordination experience
Customer service expert with excellent organizational and time-management skills
Department: Ascension Care Management Insurance
Responsible for accuracy and completeness of precertification and referral information within the database in accordance with all compliance and regulatory requirements.
Computer savvy and data entry skills
Utilization Management Assistant Jobs
By Lehigh Valley Health Network At , Allentown, 18103
2 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.
Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.
Knowledge of electronic medical records (EMR) and medical terminology.
Ability to take direction, offer useful insight into work processes & brainstorm when challenges arise. Strong ability to work collaboratively.
Retrieves medical records and scans documents to assist with the facilitation of the UM department.
Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.
Utilization Management Rep Ii
By Elevance Health At , Cerritos, 90703 $15.96 - $28.73 an hour
Medical terminology training, time management skills, organizational skills
Preferred Skills, Capabilities and Experiences:
May act as liaison between Medical Management and internal departments
This position can be filled at Utilization Management Representative II.
Manage incoming calls or post services claims work
Determine contract and benefit eligibility
Admissions Utilization Management Coordinator, Crisis
By Monarch NC At , Charlotte
Demonstrate knowledge of emergency procedures and assist in crisis situations.
Complete all other relevant responsibilities as assigned by the supervisor.
Enter screening and referral information in the electronic health record system.
Completes record audits for adherence to Service Definitions, UM Guidelines, DHSR and Accrediting bodies.
Participate in on call and afterhours coverage, including weekends and holidays as needed.
Driving and travel may be required.
Utilization Management Clinical Consultant
By CVS Health At , Baton Rouge $28.25 - $60.50 an hour
3+ years clinical practice experience, e.g., hospital or behavioral health setting,
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.
Utilization review experience strongly preferred.
Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Medical Director Ii - Utilization Management
By Devoted Health At , Remote $280,000 - $325,000 a year
Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.
Five or more years of clinical practice experience.
Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions.
Participate in inter-rater reliability activities.
Participate in analysis of utilization data and suggest improvement opportunities.
Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility.
Utilization Management Clinical Consultant
By CVS Health At , $28.25 - $60.50 an hour
3+ years clinical practice experience, e.g., hospital or behavioral health setting,
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.
Utilization review experience strongly preferred.
Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Utilization Management Administration Coordinator
By Humana At ,
Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
1 or more years of Administrative support, Healthcare, or telephonic Customer Service experience
Excellent verbal and written communication skills
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
CGX experience with building cases and generating letters
Proficient and/or experience with medical terminology and/or ICD-10 codes
Utilization Management Clinical Consultant
By CVS Health At , Galveston $28.25 - $60.50 an hour
3+ years clinical practice experience, e.g., hospital or behavioral health setting,
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.
Utilization review experience strongly preferred.
Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Utilization Management Coordinator I
By Florida Cancer Specialists & Research Institute At ,
Works closely with management team in business office to ensure all internal and external customer service issues are addressed. -
Obtain authorizations for all internal services from patient’s PCP and/or managed care companies. -
Must have excellent interpersonal and communication skills, be very detail-oriented and a self-starter.
Verify Medicaid patient eligibility status for established patients. -
Obtain authorizations for Medipass patients. -
Review daily schedules for potential pitfalls of unusual patient insurance coverage limitations or restrictions.
Utilization Management Administration Coordinator
By Humana At , , Ky
Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
1 or more years of Administrative support, Healthcare, or telephonic Customer Service experience
Excellent verbal and written communication skills
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
CGX experience with building cases and generating letters
Proficient and/or experience with medical terminology and/or ICD-10 codes
Pharmacist Utilization Management Remote With Ca Or Wa Licensure
By Molina Healthcare At , Long Beach, 90802, Ca $80,412 - $156,803 a year

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

To all current Molina employees:

Utilization Management Support Coordinator, Dentaquest (Remote)
By DentaQuest At United States
Communicate to management ways to improve processes and productivity of company.
Investigate and manage orthodontic reimbursement inquiries with Client/Provider Engagement, Claims, and Customer Service departments.
Coordinate, manage and distribute incoming faxes to facilitate distribution to appropriate parties within the organization.
Organize, coordinate, and communicate Outpatient Facility Requests to appropriate State and/or Managed Care Organizations.
1 year experience in clerical setting
Knowledge of general computer software.
Utilization Management Coordinator Jobs
By University Hospital, Newark NJ At , Newark, 07103, Nj

Responsibilities: The primary purpose of the Utilization Management Coordinator (UMC) position is to coordinate the patient’s progress through the system. He/she collaborates with physicians and ...

Are you looking for a challenging and rewarding role in Utilization Management? We are looking for a highly motivated individual to join our team as a Utilization Management Processor. You will be responsible for reviewing and processing utilization management requests, ensuring accuracy and compliance with all applicable regulations. You will also be responsible for providing support to other departments and stakeholders. If you are looking for an opportunity to make a difference and be part of a dynamic team, this is the job for you!

Overview:

Utilization Management Processors are responsible for ensuring that healthcare services are provided in a cost-effective manner. They review and analyze medical records to ensure that services are medically necessary and that they are being provided in the most cost-effective manner. They also work with providers to ensure that services are being provided in accordance with established guidelines.

Detailed Job Description:

Utilization Management Processors are responsible for reviewing and analyzing medical records to ensure that services are medically necessary and that they are being provided in the most cost-effective manner. They also work with providers to ensure that services are being provided in accordance with established guidelines. They must be able to interpret medical records and understand the medical necessity of services. Utilization Management Processors must be able to communicate effectively with providers and other healthcare professionals. They must be able to identify potential cost savings opportunities and recommend changes to improve the cost-effectiveness of services.

What is Utilization Management Processor Job Skills Required?

• Knowledge of medical terminology and coding
• Knowledge of healthcare regulations and guidelines
• Ability to interpret medical records
• Ability to identify potential cost savings opportunities
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Proficiency in computer applications such as Microsoft Office

What is Utilization Management Processor Job Qualifications?

• Bachelor’s degree in healthcare administration, business administration, or related field
• Previous experience in utilization management or healthcare administration
• Certification in utilization management or healthcare administration

What is Utilization Management Processor Job Knowledge?

• Knowledge of healthcare regulations and guidelines
• Knowledge of medical terminology and coding
• Knowledge of healthcare reimbursement systems
• Knowledge of healthcare quality improvement initiatives

What is Utilization Management Processor Job Experience?

• Previous experience in utilization management or healthcare administration
• Experience working with providers and other healthcare professionals

What is Utilization Management Processor Job Responsibilities?

• Review and analyze medical records to ensure that services are medically necessary and that they are being provided in the most cost-effective manner
• Work with providers to ensure that services are being provided in accordance with established guidelines
• Identify potential cost savings opportunities and recommend changes to improve the cost-effectiveness of services
• Communicate effectively with providers and other healthcare professionals
• Monitor and report utilization trends and patterns
• Maintain accurate records and documentation