UM Case Specialist

Provides administrative support to the Utilization Management Department by assisting with the denial, appeal and complaint process, handling reporting functions, screen/assist with incoming calls and assisting the Utilization Management staff as needed to increase departmental productivity. Carries out all duties while respecting member and provider confidentiality and promoting the mission and philosophy of the organization supported.

Essential Functions

• Types, mails, and logs denial and appeal and complaint letters.
• Generates reporting data for the health plans regarding denials, appeals and complaints on a monthly basis.
• Maintains filing system for denials, appeals and complaints.
• Accepts incoming calls and screens or resolves calls in accordance with plan design and authorization requirements.
• Enters authorizations for services as delegated by assignment.
• Runs and distributes reports from VBA data bases including authorization letters, daily authorization reports sent to health plans, and monthly statistical reports for management.
• Creates and designs forms and reports as needed.
• Maintains UM Committee minutes and updates UM Policy & Procedures as needed.

Other Duties And Responsibilities

• Assists supervisors with special projects as needed.
• Performs other duties as assigned.
• Maintains departmental data entry manual and edits content and updates format as needed.
• Maintains files.
• Provides desktop support to the department.

Minimum Qualifications

Education: High school diploma or equivalent.

Experience: Previous clerical experience, preferably in a managed care or medical management environment

Knowledge, Skills, And Abilities

• Knowledge of or ability to learn Microsoft Access
• Knowledge of or ability to learn medical terminology
• Skill with operating PC and using word processing and spreadsheet software applications