UM Case Representative

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] • 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. Equal Opportunity is the Law EEO is the Law Supplement IER Right to Work FMLA E-Verify Pay Transparency Rooted in Wyoming, Blue Cross Blue Shield Wyoming is a not-for-profit health insurer with offices throughout the state. Ever since a small group of caring, persistent Wyoming women helped us put down roots in 1945, everything we do is aimed at better healthcare for the people of Wyoming. Our mission is to help Wyoming citizens receive and pay for the healthcare they need to live healthy and productive lives. Are you interested in joining the largest, most experienced insurer in Wyoming? If you're are committed to customer service above all else, you would be a great fit for a career with us.

Salary : $34,300 - $43,400