Utilization Management Services Rep I

Job Summary

This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. The role acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment.

• Facilitate inbound and outbound calls to customers (members and providers) by delivering excellent customer‑centered service and providing information regarding services in a call center environment.
• Respond to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies.
• Perform triage for UM Services.
• Serve as the primary contact for providers regarding authorization requests.
• Contact members and providers concerning regulatory requirements relating to Department of Health (DOH) notifications and other regulatory requirements such as the National Committee for Quality Assurance (NCQA) guidelines.
• Provide timely response to all research inquiries from other departments and assure the response is thorough, accurate, and within regulatory time frames.
• Process fax requests from the designated fax and system queues.
• Consistently demonstrate high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintain high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintain regular and reliable attendance.
• Perform other functions as assigned by management.

• Assist and perform tasks associated with project and departmental management.
• Backup Team Leads by assisting with questions when needed.
• Work on assigned offline projects.
• Provide, prepare, and assist with preliminary support to multiple levels of providers and members (e.g., physicians, skilled nursing facilities, mid‑level providers, pharmacies, pharmacists, and support staff).
• Provide one‑on‑one support, coaching, and training to UM Services Reps.
• Collaborate with other key departments (Claims, Customer Service, related care management units) to ensure end‑to‑end process for authorizations, telephonic notifications, and/or care management referrals is accurate and complete.

• Assist Team Leads with assigned tasks (e.g., authorizations, claims, care management referrals, monitoring and controlling inventory levels/call queues, timeliness, reporting).
• Meet departmental requirements for Facets UM Services workflows and PEGA.
• Resolve escalated customer questions and complex concerns.
• Assist Medical Directors with scheduling Fair Hearings.
• Assist with coordinating Grievance and Appeals requests.
• Assist with all Blue Card Claims escalations.
• Assist management with the review and creation of desk‑level procedures, acting as a subject matter expert for UM Services.

• High School Diploma or GED.
• Experience with using a desktop computer in a professional environment, preferably with Microsoft Office products.
• Call center experience preferred, not required.
• Strong analytical and problem‑solving skills.
• Strong written and verbal communication skills and ability to work within a team.
• Demonstrated organizational skills to manage multiple projects and priorities.
• Self‑motivated and able to work independently, as well as on intra‑ and inter‑departmental teams where needed.

• 2 years’ experience working with managed care or healthcare industry.
• Ability to apply in-depth knowledge of complex rules, such as those of the authorization process, regulatory processes/time frames, care management systems and processes, departmental policies and procedures, product lines, and contract benefits.
• Advanced skills working between multiple programs and applications simultaneously.
• Demonstrates willingness to develop collaborative solutions to achieve a better end‑to‑end process.
• Demonstrates proficiency in basic navigation and utilization of department‑specific applications.
• De…