The Utilization Management Case Aide supports the Utilization Management team through non-clinical referral activities and clerical assistance. Day-to-day they will perform data entry, monitor cases to ensure compliance and escalate issues to leadership. This role will collaborate with clinicians to ensure cases are completed in accordance with Bright policies and procedures to support optimal care for our members. Also, the Case Aide will support the communication between Bright clinicians and provider partners. ,



ROLE RESPONSIBILITIES 

1. Provides data entry, filing, tracking time frames and status of case files and providing written and verbal notification of determination to members and providers.

2. Prepares necessary documentation for utilization management and appeals processes, performs data management and coordinates communication between members of the UM and Appeals teams to ensure timely follow through.

3. Assist in setting up communications with payors and/ or physicians as applicable including the use of fax and phone calls.

4. Reviews providers' requests for services and coordinates utilization/appeals management review.

5. Notifies Department Leadership of potential missed timeframes for submission and follow-up on responses and escalates cases as appropriate.

6. Serves as a liaison between patient account services, physicians, care coordinators, Utilization and Appeals Managers, physician advisors and facility departments.

7. Other duties as assigned.



Experience/Requirements:

• High School Diploma required; Associate or Bachelors’ Degree preferred

• Medical Assistant experience preferred

• Three (3)+ years of healthcare industry experience

• Working knowledge and understanding of basic utilization management concepts required

• Prior working experience at a health plan required

• Telephone unit background, or customer service, or call center background required.



Benefits: Medical, Dental, Vision. HSA, FSA. EAP, Commuter Benefits, 401K, PTO, Parental Leave