Utilization Review Specialist
Southeastrans Inc
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.
- 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.
- High School graduate or equivalent.
- 2 years of customer service experience and or employment in the healthcare industry.
Vacancy posted 2 days ago
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