Utilization Management Services Rep I - CDPHP

Summary This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. It acts as a resource for both internal and external customers by completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, the Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment. Essential Accountabilities Level I: Facilitates inbound/outbound calls to customers, delivering excellent customer-centered service and providing information regarding services in a call center environment. Responds to customers professionally and efficiently. Performs triage for UM Services. Serves as the primary contact for providers regarding authorization requests. Contacts members and providers concerning regulatory requirements related to Department of Health notifications and National Committee for Quality Assurance guidelines. Provides timely responses to research inquiries from other departments, ensuring answers are thorough, accurate, and within regulatory timeframes. Processes fax requests from designated fax and system queues. Demonstrates high standards of integrity, supporting the company’s mission and values. Maintains member privacy in accordance with corporate policies. Expects regular and reliable attendance. Performs other functions as assigned by management. Level II (in addition to Level I responsibilities): Assists with project and departmental management tasks. Backs up Team Leads and answers questions when needed. Works on assigned offline projects. Provides preliminary support to physicians, skilled nursing facilities, mid-level providers, members, pharmacies, pharmacists, and support staff. Provides one-on-one support, coaching, and training to UM Services Reps. Collaborates with Claims, Customer Service, and care management units to ensure end-to-end authorization processes and referrals. Level III (in addition to Level II responsibilities): Assists Team Leads with assigned tasks, including authorizations, claims, referrals, inventory monitoring, and reporting. Meets departmental requirements for FACETS UM Services workflows and PEGA. Resolves escalated customer questions and complex concerns. Assists Medical Directors with scheduling Fair Hearings. Assists with coordinating Grievance and Appeals requests. Assists with Blue Card Claims escalations. Assists management with review and creation of desk-level procedures, acting as a subject matter expert for UM Services. Qualifications High School Diploma or GED. Experience with desktop computers in a professional environment; proficiency in Microsoft Office. Call center experience preferred but not required. Strong analytical and problem-solving skills. Strong written and verbal communication skills. Organizational skills to manage multiple projects and priorities. Self‑motivated and able to work independently and within teams. Additional Requirements by Level Level II: 2 years’ experience in managed care or healthcare; in-depth knowledge of authorization processes, regulatory timelines, care management systems, policies, contract benefits; advanced multitasking skills; collaborative solution development; proficiency with department-specific applications; consistent demonstration of role-specific competencies; willingness to train new staff and take on new challenges. Level III: 4 years’ experience in managed care or healthcare; thorough knowledge of health plan contracts and coverage; operational knowledge of FACETS application and workflows; ability to resolve customer inquiries across multiple plans with limited assistance; ability to identify systemic issues and report them; independence in collaboration and problem resolution. Physical Requirements Ability to work prolonged periods sitting at a workstation and using a computer. Ability to work while sitting and/or standing for three (3) or more hours at a time. Ability to work in a home office for continuous periods of time for business continuity. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. Manual dexterity including fine finger motion. Repetitive motion required. Ability to hear, understand, and speak clearly while using a phone, with or without a headset. Compensation Compensation Range(s): N3 – Min $18.55, Mid $22.72, Max $26.90. The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on budget availability and the applicant’s experience, knowledge, skill, and education as it relates to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Benefits Other components of the total rewards package may include group health and/or dental insurance, a retirement plan, a wellness program, paid time off, and paid holidays. Potential for remote work within all jobs posted by the CDPHP Talent Acquisition team is available on a case‑by‑case basis. Equal Opportunity Employer In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. #J-18808-Ljbffr