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.