Anthem Utilization Management Representative I/II -WAH- 133621 in Atlanta, Georgia

  • Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. *

  • This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company. *

Utilization Management Rep I-III

  • Manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.*

Description

Level I:

Responsible for coordinating cases for precertification and prior authorization review.

Primary duties may includes, but are not limited:

• Managing incoming calls or incoming post services claims work.

• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.

• 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.

• Checks benefits for facility based treatment.

• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Level II:

Responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

Primary duties may include, but are not limited to:

• Managing incoming calls or incoming post services claims work.

• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service 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.

Qualifications

Level I:

• Requires High school diploma/GED;

• 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.

Level II:

• Requires HS diploma or equivalent;

• 2 years customer service experience in healthcare related setting and medical terminology training;

• or any combination of education and experience, which would provide an equivalent background.

  • Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. *

Job Customer Service

Equal Employment Opportunity Statement Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.

Title: Utilization Management Representative I/II -WAH- 133621

Location: georgia-Atlanta

Requisition ID: 133621