Utilization Management Rep - (US-CA-Camarillo - 93012)

Minimum Education: Tech School
Job Type: Full Time
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WellPoint
is the nation's leading health benefits company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to be the most trusted choice for consumers and a leader in affordable quality care with an unyielding commitment to meeting the needs of our diverse customers.
Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Responsible for coordinating cases for precertification and prior authorization review. Primary duties may includes, but are not limited: Manages incoming calls, including triage, opening of cases and authorizing sessions. Refers cases requiring clinical review to a Nurse reviewer. Responsible for the identification and data entry of referral requests into the UM 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. May act as liaison between Medical Management and internal departments. Assists in finding non-par providers. Under limited supervision, works on problems of diverse scope where analysis of data requires evaluation of identifiable factors. Knowledge of health plans, including familiarity with prior authorization and pre-certification process. Knowledge of contracts and strong knowledge of managed Benefit Programs. Able to resolve diverse and complex inquiries/situations through advanced analytical and problem solving skills.

Skills:
Requires High school diploma; 1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background. Medical terminology training and experience in medical or insurance field preferred. Excellent PC skills required requires extensive knowledge of WMDS system, prior experience as UMR Representative and Medical Terminology WellPoint is ranked No. 1 among health insurers on Fortune Magazine's annual list of America's Most Admired Companies and has been named as one of the Top 50 Companies for Diversity by DiversityInc Magazine.

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