Job description

The Utilization Review Specialist is responsible for the process of monitoring the use, delivery, and cost-effectiveness of services for eligible Medicaid members’ transportation requests to Medicaid billable services as identified by the Department of Community Health’s Policy and Procedure Manual for Non-Emergency Medical Transportation (NEMT).

ESSENTIAL FUNCTION

The primary responsibility of this role consists of ensuring that the contractual responsibilities of the organization are adhered to as it pertains to NEMT, which is accomplished through the review of all transportation requests that fall outside of these guidelines.

• Reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and or locations.

• Responsible for reviewing and making approval/denial determinations for facilities wishing to participate in the organization’s Subscription/Standing Order Transportation Program.

• Responsible for reviewing Subscription/Standing order transportation requests from approved facilities for NEMT.

• Investigates transportation provider complaints lodged against Medicaid members during transportation and issuance of Member Warning Letters as warranted.

• Responsible for completing the three departmental reports: daily denial letters, member no-show letters and monthly denial summary.

MINIMUM REQUIRED EDUCATION/TRAINING

• High School graduate or equivalent

• Healthcare-related education

• 2 years of customer service experience and or employment in a paid healthcare-related work setting

PREFERRED CANDIDATE :

• Knowledge of Medicare and Medicaid, community resources, dialysis, and the nursing home placement process.

• Must possess entry to mid-level proficiency in Microsoft Word and Excel.

• Excellent written and verbal communication skills.

• Possesses and demonstrates multi-tasking skills in a high-stress environment while working with multiple internal departments, as well as external entities.

• Analytical thinker with good judgment.

• Well-organized, self-directed individual, who is flexible and takes direction well.

• Possesses a high level of interpersonal skills to handle sensitive and confidential situations.

Job Type: Full-time

Pay: $17.00 per hour

Benefits:

• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Villa Rica, GA: Reliably commute or planning to relocate before starting work (Required)

Work Location: In person

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