Nashville, United States
about 1 year ago
Delivers specific delegated Utilization Management tasks assigned by a supervisor. Serves as initial contact for clients and their eligible dependents requesting services. Responsible for customer service and relevant standards such as telephone response time. Supports and assists with training for employees. May provide guidance around procedures and workflows. Completes day-to-day Intake Care tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. Description
Team within the coverage determinations department that is responsible for reviewing coverage determinations for timeliness to determine whether or not they are out of compliance and require auto-forwarding.
This individual will participate in reviewing monitoring reports to proactively identify high-risk cases and take necessary action to prevent them from going out of compliance.
This individual must be able to identify and properly express root cause for out of compliance cases as part of the auto-forward process.
Responsible for reviewing and monitoring various reports and/or queues to identify high risk or out of compliance cases.
Take appropriate action when necessary to prevent high risk cases going out of compliance.
Inputting and processing out of compliance cases and appropriately documenting and communicating with team.
Assist the Part D Coverage Determinations and Appeals teams with out of compliance cases to identify trends and develop strategies.
Work with the Part D Coverage Determinations and Appeals leadership to develop a sound SOP and other ongoing training materials to ensure team remains compliant with CMS timeframes.
Other special projects assigned by management.