Utilization Review Specialist

Summary:

The primary responsibility of this role consists of reviewing member transportation requests that are over the contractual mileage guidelines.

ESSENTIAL FUNCTIONS

Reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and or locations. Review for approval/denial determinations for facilities wishing to participate in the organization's Subscription/Standing Order Transportation Program. Process subscription/Standing order transportation requests from approved facilities for NEMT. Investigates transportation provider complaints lodged against Medicaid members during transportation and issuance of Member Warning Letters as warranted. Responsible for completing the three departmental reports: daily denial letters, member no-show letters, and monthly denial summary. Run Monthly Denial Summary Report for covered regions and send to the client. Required Skills and Abilities Knowledge of Medicare and Medicaid, community resources, dialysis, and the nursing home placement process. Must possess entry to mid-level proficiency in Microsoft Word and Excel. Excellent written and verbal communication skills. Possesses and demonstrates multi-tasking skills in a high-stress environment while working with multiple internal departments, as well as external entities. Analytical thinker with good judgment. Well-organized, self-directed individual, who is flexible and takes direction well. Possesses a high level of interpersonal skills to handle sensitive and confidential situations. Minimum Required Education/Training High School graduate or equivalent. 2 years of customer service experience and or employment in the healthcare industry.