UM - Informed Choice Representative

Job Title

UM Informed Choice Representative

Department

UM Informed Choice

Reports to

Supervisor

Vice President

Business Development

Nature of Work in this Position: This position involves the initial and on-going coordination of the precertification process in the department. On-island processing involves intake from fax or walk in from members, making entries in the referral system and eventually sending back the determinations. Off-island referral is through intake of off-island service requests from members and providers, scheduling of appointments and/or procedures, preparation of pertinent referral documents for review by the Supervisor/Manager or Director of Medical Care Management and Quality Assurance and notification of members regarding their care options. This position calls for daily interaction and communication with members, providers, third party representatives and other personnel involved in a medical referral.

Illustrative Examples of Work:

• Assist the Utilization Management Coordinator in the intake and processing of On-island and Off-island pre-certification request.
• Assist the Medical Care Management Coordinator in obtaining medical records from providers;
• Communicate with members about care options, treatment alternatives, company procedures, and Plan benefits/exclusions to assist them in making informed choices about their health while fostering good provider relations with existing network of participating physicians and facilities;
• Prepare the referral forms and the system documentation required for review by the UM Informed Choice Coordinator;
• Schedule, confirm and coordinate member-physician appointments, procedures and/or medical flight or ambulance arrangements;
• Release the Off-island Referral Packet to the member while obtaining his/her acknowledgment of understanding the process;
• Receive member and provider complaints and grievances for appropriate referral to the Medical Care Management Coordinator or department Supervisor/Manager.
• Prepare reports as assigned by the department Supervisor/Manager or Director of Medical Care Management and Quality Assurance;
• Maintain the department’s template referral forms under the supervision of the department Supervisor/Manager;
• Assist in the processing of airfare vouchers (and reimbursements) for eligible members;
• Assist the department Supervisor/Manger and Coordinator in gathering data and preparation of materials for quality assurance and improvement;
• Assist the UM/QA-QI Manager and Coordinator in disseminating information to members about quality assurance and improvement;
• Assist the UM/QA-QI Manager and Coordinator in maintaining all appropriate records and documentation;
• Assist the UM/QA-QI Manager and Coordinator in the progress of QA-QI activities;
• Performs related duties as required. (Related duties are duties that may not be specifically listed in the class specification or position description, but that are within the general occupational series and responsibility level typically associated with the employee’s class of work.)

Knowledge / Skills / Abilities:

• Ability to clearly communicate to members plan benefits, limitations and exclusions
• Ability to respond to common inquiries or complaints from providers or customers, outside agencies, or members of the health care community
• Ability to prepare routine letters and reports that conform to prescribed style and format
• Ability to work under the stress of meeting many requests from various departments and individuals, sometimes with conflicting deadlines
• Ability to meet attendance standards
• Knowledge of medical terminology
• Excellent organization and customer relations’ skills

Minimum Experience and Training:

• High school diploma or its equivalent;
• Minimum two (2) years’ work experience in a health insurance or health care organization, including significant exposure to assisting clients and customers;
• Any equivalent combination of training and experience that will provide the required skill and knowledge for successful performance of the job;
• Proficient in the use of Microsoft Office (Word, Excel, PowerPoint, Outlook); and
• Computer literate (Windows).

Note: This job specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.

This job entails access to PHI / ePHI data. Any personally identifiable health information, including genetic and demographic data, collected from an individual by a covered entity. This includes information related to an individual’s past, present, or future physical or mental health, healthcare provision, or payment. PHI includes information like the patient’s name or other identifiable data. It excludes information in education records and employment records held by a covered entity. PHI also excludes information related to individuals who have been deceased for more than 50 years. The hired individual is expected to maintain policies and procedures to ensure compliance with HIPPAA regulations in handling PHI/ePHI data.

Pay: $11.19 per hour

Expected hours: 40.0 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person