This is an office based position in Richmond, VA. The hours are Mon-Fri, 8am-5pm est.The Healthcare Support Specialist contributes to administration of utilization management and performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.
The Healthcare Specialist provides non-clinical support for the policies and procedures ensuring best and most appropriate treatment, care or services for members. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction. Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.
The Utilization Management Specialist functions under the direction of the Supervisor, Utilization Management and/or designee to coordinate, generate and track both incoming and outgoing correspondence, related to the member for services or prospective services. Interacts with members, providers, facilities and other Humana staff to implement the program interventions, facilitate receipt of information and records for prompt review and response by the clinical staff.
Supports the daily operations of Utilization Management team through interaction with staff, facilities, vendors and providers
Maintains a current knowledge base of Utilization Management processes and timelines
Uses good listening skills, conducts outreach calls, collecting data according to script, tools, and protocols meeting both productivity and performance expectations as identified by departmental supervisor/or designee. Conducts all calls in a courteous and customer service friendly manner. Refers as appropriate when indicated by workflow
Creates, updates maintains and/or closes authorizations or tasks for services as assigned within process guidelines. Routes case to appropriate Humana associates based on established guidelines
Processes all incoming and outgoing correspondence/faxes in accordance with required standards and within respective timeliness guidelines. Refers to the appropriate clinical team members for review as defined by workflow
Performs in a call center environment appropriately processing or triaging calls from members and providers
Clerical responsibilities such as processing urgent scanning, mailing requests, document retrieval, and projects as assigned
Demonstrates a professional and courteous manner when communicating with others with the ability to clearly and accurately state the agreed upon resolution
Adhere to Humana Policies and Procedures, process standards, and Standard Operating Procedures
Performs other related duties and projects as assigned within the assigned timeframes
Complies with Humana and HIPAA confidentiality standards to protect the confidentiality of member information
High School Diploma Required, Associate’s Degree+ preferred
Administrative or technical support experience
Excellent verbal and written communication skills
Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems
Working knowledge of MS Office including Word, Excel, and Outlook in a Windows based environment
Proficient utilizing electronic medical record and documentation programs
Proficient and/or experience with medical terminology and/or ICD-10 codes
+ + Bachelor’s Degree in Business, Finance or a related field
Prior member service or customer service telephone experience desired
Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
Scheduled Weekly Hours
Equal Opportunity Employer
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