UM Rep II- (Behavioral Health)- 41935 - (US-MO-St. Louis - 63199)

Minimum Education: Tech School
Job Type: Full Time
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Manages incoming calls, including triage, opening of cases and authorizing sessions. Determines contract and benefit eligibility; provides authorization for inpatient admission and outpatient precertification and/or prior authorization 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. Authorizes initial set of sessions to provider. Checks benefits for facility based treatment. 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. Medical terminology training required. Able to serve as resource or leadership role when necessary. Orients new staff to basic job functions. Computer skills, problem solving, strong organization, written and oral skills. Coding skills.

Skills:
High school diploma or equivalent combination of education and experience required. Min two years customer service experience in healthcare related setting. Strong PC skills required; able to navigate through various screens to assist customers.


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