Utilization Review Jobs in Rochester, NY (NOW HIRING)

This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment.

Essential Accountabilities:

Level I

• Facilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environment.
• Responds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies.
• Perform triage for UM Services.
• Serves as the primary contact for providers regarding authorization requests.
• Contacts members and providers concerning regulatory requirements relating to Department of Health (DOH) notifications and other regulatory requirements such as the National Committee for Quality Assurance (NCQA) guidelines.
• Provides timely response to all research inquiries from other departments and assures the response is thorough, accurate, and within regulatory timeframes.
• Processes fax requests from the designated fax and system queues.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Assists and performs tasks associated with project and departmental management.
• Backup Team Leads by assisting with questions when needed.
• Work on assigned offline projects.
• Provide, prepare, and assist with preliminary support to multiple levels of providers and or members (as well as others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers, members, pharmacies, pharmacists, and support staff.
• Provide one-on-one support, coaching, and training to UM Services Reps.
• Collaborates with other key departments (Claims, Customer Service, related care management units) to ensure end-to-end process for authorizations, telephonic notifications, and/or care management referrals is accurate and complete.

Level III (in addition to Level II Accountabilities)

• Assists Team Leads with assigned tasks when necessary (including but not limited to authorizations, claims, care management referrals, monitoring and controlling inventory levels/call queues, timeliness, reporting).
• Meet departmental requirements for Facets UM Services workflows and PEGA.
• Resolves escalated customer questions and complex concerns.
• Assists Medical Directors with scheduling Fair Hearings.
• Assists with coordinating Grievance and Appeals requests.
• Assist with all Blue Card Claims escalations.
• Assist management with the review and creation of desk level procedures, acting as a subject matter expert for UM Services.

Minimum Qualifications:

All Levels

• High School Diploma or GED.
• Experience with using a desktop computer in a professional environment, preferably with Microsoft Office Products.
• Call center experience preferred, not required.
• Strong analytical and problem-solving skills.
• Strong written and verbal communication skills and ability to work within a team.
• Demonstrated organizational skills to manage multiple projects and priorities.
• Self-motivated and able to work independently, as well as on intra- and inter-departmental teams where needed.

Level II (in addition to Level I Qualifications)

• 2 years' experience working with managed care or healthcare industry.
• Ability to apply in-depth knowledge of complex rules, such as those of the authorization process, regulatory processes/time frames, care management systems and processes, departmental policies and procedures, product lines, and contract benefits.
• Advanced skills working between multiple programs and applications simultaneously.
• Demonstrates willingness to develop collaborative solutions to achieve a better end-to-end process.
• Demonstrates proficiency in basic navigation and utilization of department specific applications.
• Demonstrates role-specific competencies as it pertains to their work unit on a consistent basis.
• Active demonstration of broad knowledge base and positive work habits as evidenced by ability to train new staff, take on new challenges, flexibility in work assignments, and participation in meetings and projects as assigned.

Level III (in addition to Level II Qualifications)

• 4 years' experience working with managed care or healthcare industry.
• Demonstrates a thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff and other areas within the company with related inquiries.
• Demonstrates operational knowledge of FACETS application and workflow processes
• Ability to resolve/respond to customer inquiries across multiple plans with limited assistance.
• Ability to collaborate within the organization when issues arise with limited assistance.
• Ability to identify potential systemic issues and report as necessary without supervisor assistance.

Physical Requirements:

• Ability to work prolonged periods sitting at a workstation and working on a computer.
• Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Manual dexterity including fine finger motion required.
• Repetitive motion required.
• The ability to hear, understand and speak clearly while using a phone, with or without a headset.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s): N3 - Min $20.00 Max $26.90

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.