What are the responsibilities and job description for the UM Case Representative position at Blue Cross Blue Shield of Wyoming?
Job Description Summary:
Job Description:
Blue Cross Blue Shield of Wyoming Job Description
Job Title UM Case Representative
Job Code 015-10
Reports To UM Supervisor
Department Medical Review
Last Revision Date April 2018
Revised By Renee Dilly
GENERAL PURPOSE
Gather, organize and coordinate all work received into the Utilization Management department and enter in the UM processing system.
ESSENTIAL DUTIES/RESPONSIBILITIES [Core 25d]
OTHER DUTIES/RESPONSIBILITIES
SUPERVISORY DUTIES
None
JOB QUALIFICATIONS
KNOWLEDGE, SKILL & ABILITY: [Core 25b]
EDUCATION, LICENSURE, OR FORMAL TRAINING: [Core 25a & 25c]
EXPERIENCE: [Core 25a]
MATERIAL AND EQUIPMENT DIRECTLY USED:
WORKING ENVIRONMENT/PHYSICAL ACTIVITIES:
ACCESS TO PROTECTED HEALTH INFORMATION (PHI)
Job Title UM Case Representative
Job Code 015-10
Reports To UM Supervisor
Department Medical Review
Last Revision Date April 2018
Revised By Renee Dilly
GENERAL PURPOSE
Gather, organize and coordinate all work received into the Utilization Management department and enter in the UM processing system.
ESSENTIAL DUTIES/RESPONSIBILITIES [Core 25d]
- Works towards quality initiatives
- Review all work received into the Utilization Management department
- Transcribe all department voice mails into the UM system
- Make calls to members and providers when additional information is required
- Enter cases into the UM system and forward to clinical staff for review
- Review cases returned from clinical staff to ensure appropriate letter is generated
- Initiate and monitor any reports necessary to operate efficiently
OTHER DUTIES/RESPONSIBILITIES
- Engages in screening activities that do not require clinical evaluation or interpretation, including review of appeal requests for completeness, collection and transfer of non-clinical data, or acquisition of structured clinical data. [HUM 7]
- Has access for consultation to licensed clinicians, while conducting all screening activities. [HUM 8]
- Keep all subscriber Personal Health Information (PHI) confidential
- Interact well with other departments
- Follow and adhere to appropriate guidelines and laws applicable to duties (HIPAA, ERISA, URAC, etc.)
- Other duties as assigned.
SUPERVISORY DUTIES
None
JOB QUALIFICATIONS
KNOWLEDGE, SKILL & ABILITY: [Core 25b]
- Must have good organizational skills
- Computer literacy and the skill required to complete job functions
- Must be knowledgeable about and/or have the ability to learn various computer applications including Microsoft (MS) Word, MS Excel and MS Access
- Professional phone and communication skills required
- Must be self-motivated, a quick learner and have the ability to adapt to change
- This position works under general supervision; work is subject to specific performance and accuracy guidelines or specified production time [HUM 7]
EDUCATION, LICENSURE, OR FORMAL TRAINING: [Core 25a & 25c]
- High School degree or equivalent
- Experience in health and/or health related field is desired
EXPERIENCE: [Core 25a]
- Two (2) years prior office experience preferred. Experience in health and/or health related field is desired.
MATERIAL AND EQUIPMENT DIRECTLY USED:
- Computer
- Electronic health care processing software
- Microsoft Office
- Various on-line software
- Fax, copy and scanning machines
- Telephone
WORKING ENVIRONMENT/PHYSICAL ACTIVITIES:
- Works in an open office environment.
- Physical activities include, but are not limited to, keyboard and mouse manipulation, hand carrying items short distances to various other departments.
ACCESS TO PROTECTED HEALTH INFORMATION (PHI)
- Access to PHI is broad due to job function requirement of responding to customer and provider appeals relative to claims payments, eligibility, contract benefits and any other inquiry.
Blue Cross Blue Shield of Wyoming is an EOE, M/F/Vet/Disabled employer. Blue Cross Blue Shield of Wyoming uses
E-Verify to confirm employment eligibility.
E-Verify to confirm employment eligibility.
Equal Opportunity is the Law
EEO is the Law Supplement
IER Right to Work
FMLA
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Pay Transparency
Salary : $31,200 - $39,500