Utilization Review Specialist

Athens Administrators, Inc.; California; À distance; USD 60 000 - 75 000; Plein temps

Résumé du poste

Athens Administrators has an immediate need for a full-time Utilization Review Specialist to support our Managed Care department and can be located remotely if technical requirements are met and the employee resides in a state Athens operates in. The schedule is Monday-Friday from 9am – 5pm PST with a 30-minute meal break, 37.5 hours a week.

The UR Specialist assists the utilization review process taking on various tasks including data collection of demographics, claim and medical information;

Qualifications

• High School Diploma or equivalent (GED) required for all positions.
• AA/AS or BA/BS preferred but not required.
• Minimum of one year data entry experience, preferably in medical or insurance industry.
• One year work experience in corporate environment preferred.
• Knowledge of, or ability to learn, and apply basic medical terminology and ICD-9/10.
• One year customer service experience minimum.
• Time management skills and the ability to work independently to meet goals and sensitive timelines.
• Well-developed verbal and written communication skills with strong attention to detail.
• Excellent organizational skills and ability to multi-task.
• Ability to type quickly, accurately and for prolonged periods.
• Proficient in Microsoft Office Suite.
• Ability to learn additional computer programs.
• Reasoning ability, including problem-solving and analytical skills.
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization.
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results.
• Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner.
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor.

Responsabilités

• Abundant data entry.
• Enters initial data and starts workflow processes.
• Initiates and modifies demographic information, physician, and facility information, performs quality check of data feed information.
• Validates that the request for authorization is complete or requests additional data from requesting physician if necessary.
• Run request for authorizations through rules engine for direct approval.
• Assign cases to next level reviewer if they do not meet criteria for direct approval.
• Answers general phone calls and/or emails in a professional manner and directs to the appropriate party as required.
• Complete other projects and tasks as assigned by management.
• Follow all regulatory policies and procedures, privacy, and security standards in accordance with government agencies including HIPAA requirements.
• Other duties as assigned

Connaissances

Data entry

Medical terminology

Customer service

Data analysis

HIPAA compliance

Formation

AA/AS or BA/BS preferred

Outils

Microsoft Office

Description du poste

Career Ladder

Next step in progression could include Utilization Review Specialist II

ATHENS POSITION DETAILS

Position Title

Utilization Review Specialist

Department

Managed Care – Orange, CA

Reports To

Utilization Review Clinical Supervisor

FLSA Status

Non-Exempt

Job Grade

6

Career Ladder

Next step in progression could include Utilization Review Specialist II

ATHENS ADMINISTRATORS

Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!

Position Summary

Athens Administrators has an immediate need for a full-time Utilization Review Specialist to support our Athens Managed Care department and can be located remotely if technical requirements are met and the employee resides in a state Athens operates in. The schedule for this position is Monday-Friday from 9am – 5pm PST with a 30-minute meal break, 37.5 hours a week. The Utilization Review Specialist assists the utilization review process taking on various tasks including data collection of demographics, claim and medical information; non‑medical analysis; and outcomes reporting.

Primary Responsibilities

• Abundant data entry
• Enters initial data and starts workflow processes
• Initiates and modifies demographic information, physician, and facility information, performs quality check of data feed information
• Validates that the request for authorization is complete or requests additional data from requesting physician if necessary
• Run request for authorizations through rules engine for direct approval
• Assign cases to next level reviewer if they do not meet criteria for direct approval
• Answers general phone calls and/or emails in a professional manner and directs to the appropriate party as required
• Complete other projects and tasks as assigned by management
• Follow all regulatory policies and procedures, privacy, and security standards in accordance with government agencies including HIPAA requirements.
• Other duties as assigned

Essential Position Requirements

• High School Diploma or equivalent (GED) required for all positions
• AA/AS or BA/BS preferred but not required
• Minimum of one year data entry experience, preferably in medical or insurance industry
• One year work experience in corporate environment preferred
• Knowledge of, or ability to learn, and apply basic medical terminology and ICD-9/10
• One year customer service experience minimum
• Time management skills and the ability to work independently to meet goals and sensitive timelines
• Well-developed verbal and written communication skills with strong attention to detail
• Excellent organizational skills and ability to multi-task
• Ability to type quickly, accurately and for prolonged periods
• Proficient in Microsoft Office Suite
• Ability to learn additional computer programs
• Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
• Ability to be demonstrate care and concern for fellow team members and clients in a professional and friendly manner
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor
• Athens’ operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.

This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self‑education, prior experience, or on-the-job training.

Athens Administrators is an Equal Opportunity/ Aff... (truncated for brevity, content continues unchanged)