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Utilization Review Specialist
Job TitleUtilization Review Specialist
The Utilization Review Specialist is responsible for managing member utilization.
Determines member eligibility
Verifies the appropriateness of service levels
Manages the denial and appeal process
Monitors exceptional distance report
Confirms utilization of the closest medical provider of services
Assists with standing order recertification
Audits whether provider billed for previously cancelled trips and/or was paid for trips that did not occur
Performs other duties as assigned
Communication, Oral - Ability to communicate effectively with others using the spoken word
Communication, Written - Ability to communicate in writing clearly and concisely
Decision Making - Ability to make critical decisions while following company procedures
Interpersonal - Ability to get along well with a variety of personalities and individuals
Problem Solving -- Ability to find a solution for or to deal proactively with work-related problems
RelationshipBuilding -- Ability to find a solution for or to deal with customers and co-workers
High School Graduate or General Education Degree (GED) required
Prior experience in a medical office preferred; social services or case management experience is a plus
SKILLS & ABILITIES
Superior customer service and phone skills
Strong verbal communication, writing, problem solving, time management, and organizational skills
Must possess professional writing skills and ability to correspond with professionals both verbally and in writing
Ability to type 35 corrected words per minute
Must have strong spreadsheet and database skills to include intermediate proficiency with Microsoft Excel, Word and Outlook)
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to talk or hear. The employee is frequently required to use hands to finger, handle, or feel. The employee is occasionally required to stand, walk, reach with hands and arms and lift. Specific vision abilities required by this job include close vision.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Entire work time is conducted in an office environment in a controlled atmosphere building.
The noise level in the work environment is usually moderate.