Utilization Review Coordinator jobs in Wisconsin

Overview

Do you pride yourself on making work more efficient through organized, thoughtful delegation of tasks and responsibilities? Are passionate about serving the healthcare needs of members, by connecting them with the appropriate parties and resources to meet their needs? Are you dedicated to improving the quality and cultural competence of overall healthcare service delivery, and healthcare self-sufficiency of individuals everywhere?

If so, please consider joining our Utilization Management team as a Utilization Management Operations (UM) Coordinator. This role is responsible for delivering an excellent customer experience by collaborating with members and providers to coordinate care and services and serving as the primary contact for Utilization Management inquiries. The UM Operations Coordinator also reviews select prior authorization requests to complete applicable determination processing and triages incoming phone calls and urgent prior authorization requests to appropriate parties within the department.

Benefits

• Work independently while enjoying the benefits of collaborating with a team
• Make a direct, positive impact on the care and service our members receive
• Full-time virtual, telecommuting, work from home environment available, if preferred
• Ideal starting pay range, based on skills and applicable experience: $24-$30/hr, plus a robust total rewards package

Responsibilities

• Manage Medicare Prime/Quartz secondary skilled nursing facility prior authorization process, including:
  • Reviewing and processing select prior authorization requests for completeness, reach out to members for more information and to answer their questions, and processing denials for lack of information
  • Review covered benefit requests against medical necessity criteria, policies, and certificates of coverage to process approval and benefit denials
  • Prepare medical records and case notes for approvals, and present denials to Medical Director for further review, as needed
• Conduct telephonic customer service and problem solving for members and providers regarding authorization requests, hospitalizations, and claims questions
  • Triage outpatient and customer service urgent prior authorization requests
  • Assist with healthcare service coordination - collaborate with RN team to identify and prioritize high needs / risk cases, research and identify appropriate in-network services & assess specialist wait times, and assist members with care coordination and problem solving
  • Coordinate peer to peer requests between physicians
  • Perform Health Plan Transition initial screening/intake for new member coordination of care and between applicable departments
• Medical documentation and reporting - send appropriate notifications to members, providers, and facilities according to established processes & policies

Qualifications

• Associate degree or equivalent work experience in a health-related field.
• 3 years of experience working in health plan or healthcare-related operations role
• Valid Driver’s License and verifiable good driving record and reliable transportation, with the ability to travel, as necessary, to attend off-site meetings on a regular basis
• LPN preferred
• Knowledge of medical terminology, including ICD-10 and CPT/HCPCS coding (CPC certification preferred)
• Electronic health record experience preferred (i.e. EPIC)
• Advanced Microsoft Office skills
• Ability to research and analyze issues from different perspectives, organize information and work collaboratively with others to develop and implement effective solutions
• Ability to apply critical thinking skills and resolve complex problems by exercising good judgment and professional demeanor

This full-time position may work remotely, or from one of our offices located in Madison, WI or Onalaska, WI. Hardware and equipment will be provided by the company, but candidates must have access to high-speed, non-satellite Internet to successfully work from home.

Quartz offers an excellent benefit and compensation package, opportunity for career advancement and a professional culture built upon the foundations of Respect, Responsibility, Relationships & Resourcefulness. Quartz is a federal contractor and supports a safe, drug-free workplace. All employment offers are contingent upon successful completion of a pre-employment criminal background check.

Quartz values and embraces diversity and is proud to be an Equal Employment Opportunity, Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.