UM Services Representative I - 000855

Summary:

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 Responsibilities/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 essential responsibilities/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.
• Provides, prepares, and assists 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 essential responsibilities/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:

NOTE:

We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

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 minimum 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 minimum 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:

Environment/workstation

• Ability to work prolonged periodssitting at aworkstationand working on a computer.
• Abilitytoworkwhile sittingand/or standing whileat aworkstationviewing a computer and using a keyboard,mouseand/or phoneforthree (3)or more hours at a time.
• Ability to work in a home office for continuous periods of time for business continuity.

Travel

• Ability totravelacross theHealth Plan serviceregionfor meetings and/or trainings as needed.

Other Motions

• Manual dexterity including fine finger motion required.
• Repetitive motion required.

Additional Requirements on current JDs

• The ability to hear, understand and speak clearly while using a phone, with or without a headset.

The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

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

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)