Utilization Management Customer Service

1. Primary Purpose

To provide high-level customer service to PDTs’ clients with accuracy.

1. Principal Duties and Responsibilities - *Goals on Performance Review

• Answer calls from members, providers, and health plans regarding specific claim issues. Route and redirect calls as necessary.
• *Return calls from the UM voicemail box within 24 hours
• *Perform timely follow-up on calls requiring research and call back within 24 hours.
• Accurately interpret DOFRs – Division of Financial Responsibility documents to determine where specific health care services are rendered.
• Verify eligibility & benefits for each submitted physician referral by contacting health plans for pertinent information.
• Work with contracting personnel to ensure the utilization of appropriate providers.
• *Provide requested referral and network information to providers/staff promptly within 24 hours.
• Use MedMC to log incoming calls and their resolution.
• Complete other projects as assigned by the supervisor

1. Job Specifications (KSAs):
   • Requires the ability to speak, read, write, and understand English and other general educational skills, as is generally obtained by completing high school or a GED.
   • Knowledge of the health or managed care industry is generally obtained through 1-2 years of work experience.
   • Excellent communication skills with a focus on superior telephone etiquette.
   • 1-2 years of customer service experience required.

IV Position Performance Criteria

• Ability to organize and maintain multiple sets of information and data.
• Consistently produces accurate and timely work as it relates to departmental goals.
• Demonstrates high reliability through consistent punctuality and attendance.
• Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.
• Uses sound judgment regarding time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.
• Demonstrates excellent interpersonal skills as discerned through observation and team project successes.
• Accurately interprets and applies departmental policies and procedures using sound judgment.
• Communicates professionally and respectfully with peers, superiors, subordinates, and clients.
• Provides constructive feedback on assigned work projects.
• Demonstrates overall professionalism in attitude, demeanor, and personal appearance.