Utilization Mgmt Specialist (Hybrid/Troy, MI) - Health Alliance Plan
General Summary:
“Union Represented Position” providing essential administrative, authorization and organizational support to the daily operations of utilization management, care management or quality teams. This role will ensure smooth and efficient work by supporting, managing documentation, processing utilization management requests and facilitating cross-departmental communication. This position would be required to communicate with provider and members in a friendly and professional manner. Supporting all departmental activities related to the specific team aligned with.
The following job duties may vary depending on the specific team being supported.
Principal Duties and Responsibilities:
Receive and process utilization management inquiries via the phone queue and fax, which may include authorizations or appeals. Review requests for accuracy and assist with diagnostic and procedure coding utilizing CPT, HCPC and ICD-9/10 codes according to departmental standards.
Respond, research and provide support promptly to provider's/member’s requests and inquiries. Educate providers and members on benefit provisions and HAP policies and procedures. Contact providers/members to obtain information required.
Work directly with specific team aligned to regarding issues/outreach and urgent requests at the request of providers and members. Document in the appropriate platform based on workflow and regulatory requirements.
Type, process, mail, file and scan denial letters or any other materials and or correspondence/letters to members/ providers according to NCQA, CMS and DOL or any other standards and timeframes. Maintain daily log of denial activities.
Receive, filter and enter discharge data from the daily report and collaborate with facilities to obtain discharge dates for timely claims payment.
Receive email, gather and send member information for subpoena requests from the Legal department.
Retrieve, investigate, conduct research, label and attach the faxed clinical information into the care management software.
View, investigate, assist in monitoring and resolve and/or route to correct team cases assigned in the customer service software.
Retrieve messages on the after-hour voicemail and complete the log daily to remain compliant with NCQA standards.
Receive emails, referrals, phone or faxed requests, enter case into care management software and notify appropriate team for processing.
Support meetings and projects through material preparation, schedule coordination, and active participation.
Assist in workflows including requesting medical records, service reminders to ensure members and providers are completing tests and screenings impacting Hedis/Star measures.
Assist in monitoring work plans and process flows to ensure completion on tasks associated with various projects.
Assist leadership team with reviewing and sharing reports with the applicable team members and monitoring of compliance, as needed.
Perform all other related duties as assigned.
Education/Experience Required:
Associate’s degree or a minimum of four (4) years of related experience may be considered in lieu of degree.
Minimum of two (2) years of recent administrative experience in a health care setting within the last three years.
Minimum of two (2) years of recent experience providing direct communication to customers and/or providers within the last two years.
Demonstrated proficiency with MS Word and Excel.
Knowledge of basic medical terminology.
Knowledge of ICD-9, CPT, and HCPC codes.
Knowledge of hospital, HMO, and health care related procedures.
Billing or coding experience preferred.
Skills and Abilities:
Customer-focused.
Excellent telephone skills
High degree of organizational skills.
Detail oriented.
Good verbal and written skills.
Self-motivated and self-directed.
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. My Choice Rewards is a program as diverse as the people it serves. There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.