Healthcare Utilization Administrative Specialist

Under the direction of the Utilization team manager to provide administrative, operational, and organizational support for the Utilization Management teams.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

Researches, assesses, and processes all requests for authorization that are initiated through the call center as well as the “Student Away” phone line and e-mail. Authorizations or interactions are completed and documented in the HAP care management software per regulatory guidelines. Provides administrative support to management staff related to automated authorization processes, data integrity and error resolution, issues related to the interface of HNM data with HAP systems that affect payment of the claim, network assignment discrepancies, reversing payment denials and tracking of referral benefits. Provides direct and day to day resolution for issues relayed through external departments and delegates that include but are not limited Evicore (CareCoreNational) exception reports, which relate to the authorization and processing of outpatient referral activity. When indicated, contact primary care physicians and specialist providers to obtain additional information required for accurate processing of request. Develops authorization request review and present to the designated HAP Medical Director for approval or denial. Based on decisions made by designated HAP Medical Director, ensures implementation and communication of decision. Researches and (through working with the applicable clinical personnel) resolves benefit authorization issues which cannot be decided through application of Health Alliance Plan criteria. Prepares denial and approval letters in addition to other written correspondence and reports and maintains files and documents that have mandatory regulatory requirements directly impacting the company’s accreditation by NCQA and compliance with CMS and privacy policies. Provides Utilization Management staff support and liaison support to committees, including research and proposing appropriate guidelines/criteria. Actively participates in assessment and development of proposals to improve utilization patterns, reduce medical costs, enhance provider delivery system,and streamline operational aspects associated with the referral process. Responds to incoming calls, faxes, and mail. Facilitates resolution or triage appropriately to ensure timely follow‑up to each request. Enters request received via fax into the care management system. Performs other related duties as assigned.

EDUCATION/EXPERIENCE REQUIRED:

Associate’s degree required or an additional three (3) years of experience may be considered in lieu of the education requirement. Graduate from a Commission on Accreditation of Allied Health Education Programs (CAAHEP) preferred or Accrediting Bureau of Health Education Schools (ABHES) preferred. Minimum of three (3) years of experience analyzing information and coordinating projects. Experience using personal computers. Experience with medical terminology. Experience with medical billing code (CPT and ICD-9/10 coding), preferred. Experience managing multiple projects in a fast‑paced client focused Environment preferred. Ability to handle a diverse range of situations and responsibilities preferred. Proficiency with windows‑based software, including spreadsheet (EXCEL) preferred. Experience or familiarity with community support services preferred. Excellent verbal and written communication skills preferred. 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. Equal Employment Opportunity / Aff 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. #J-18808-Ljbffr Henry Ford Health System