Utilization Review Assistant - Remote

Job Description:

Position Summary

The Associate Utilization Review Assistant is responsible for providing non-clinical support to the Utilization Management (UM) Team. This role supports the operation of the UM team through internal and external customer service. eligibility verification, data entry of authorizations/organization determinations (OD), ensuring completeness of information on authorization/OD requests, assisting providers and members, and processing requests per standard work in order to ensure that Utilization Management activities are completed in a timely and accurate manner in compliance with contractual standards set forth by CMS, Tricare, and NCQA.

Job Description

Key Outcomes:

• Available on a phone queue between 8am and 430pm as needed to support the UM nurses as well as to receive authorization requests and answer general authorization questions from members and providers.
• Manages multiple authorization queues by reviewing, screening, entering, and processing authorization requests from members and providers per HMD guidelines/workflows and contractual/regulatory standards. Uploads faxes to the medical management system.
• Produces notifications by letter to members and providers as required by regulation and accreditation standards.
• Manages the notification queue and sends out daily census information to targeted facilities as needed.
• Participates in and contributes to Health Management Department meetings and process improvement initiatives.
• Complies with all contractual requirements and organizational/departmental standards regarding authorizations, clinical reviews, and provider/member communications.
• Other duties as needed, may be cross trained as back-up for other non-clinical areas of HMD as needed

Education/Experience:

• Associates Degree or equivalent education and experience
• 2 years of managed care experience including experience in a call center
• Experience with CPT, ICD-10 and HCPCS coding a plus

Required License(s) and/or Certification(s):

• Medical Assistant Certification a plus

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values
• Basic knowledge of medical terminology, current healthcare benefits and managed care insurance plans
• Basic knowledge of Microsoft Word and Excel
• Knowledge of CMS and NCQA regulations a plus
• Demonstrated technical skills in use of office systems, electronic heath records, and databases
• Strong organizational skills (ability to prioritize and multi-task in a high-pressure environment while maintaining focus on organizational objectives)
• Ability to take direction from multiple individuals and prioritize tasks appropriately to meet priorities and deadlines
• Ability to handle confidential and sensitive information in a discreet and professional manner
• Communicates effectively with both internal and external customers
• Ability to function independently
• Critical thinking: Can identify root causes and suggest creative solutions
• Takes appropriate initiative while soliciting input/advice appropriately
• Ability to collaborate with all internal departments and staff with dedication to customer satisfaction

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

About Us

Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit https://careers.martinspoint.org.