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Anthem, Inc. Utilization Management Representative I or II - Job Family in Denison, Texas

Description

SHIFT: Day Job

SCHEDULE: Full-time

Be part of an extraordinary team We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

This position can be filled at Utilization Management Representative I or Utiliztion Management Representative II level. The hiring manager will determine the level, based on the candidate’s experience and background.

Utilization Management Representative I

Responsible for coordinating cases for precertification and prior authorization review. Primary duties may include, but are not limited to:

• Managing incoming calls or incoming post services claims work. • Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests. • Refers cases requiring clinical review to a Nurse reviewer. • Responsible for the identification and data entry of referral requests into the Utilization Management system in accordance with the plan certificate. • Responds to telephone and written inquiries from clients, providers and in-house departments. • Conducts clinical screening process. • Authorizes initial set of sessions to provider. • Checks benefits for facility-based treatment. • Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Utilization Managment Representative II

Responsible for managing incoming calls, including triage, opening of cases, and authorizing sessions.

Primary duties may include, but are not limited to:

  • Managing incoming calls or incoming post services claims work.

  • Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.

  • Obtains intake (demographic) information from caller.

  • Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given.

  • Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.

  • Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization.

  • Verifies benefits and/or eligibility information.

  • May act as liaison between Medical Management and internal departments.

  • Responds to telephone and written inquiries from clients, providers, and in-house departments.

  • Conducts clinical screening process.

Qualifications

Utilization Managment Representative I

Minimum Requirements: • Requires a High School diploma or GED. • A minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background. Preferred Qualifications: • Medical terminology training and experience in medical or insurance field preferred. • For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Utilization Managment Representative II

  • Requires HS diploma or equivalent

  • Minimum of 2 years customer service experience in healthcare related setting and medical terminology training; or any combination of education and experience which would provide an equivalent background.

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Certain contracts require a Master's degree.

    Preferred:

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

  • Certain contracts require a Master's degree.

    We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state, and local laws. Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

    REQNUMBER: PS72597

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