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Utilization Review Specialist
Utilization Review SpecialistVerida Inc • Villa Rica, GA, US
Utilization Review Specialist

Utilization Review Specialist

Verida Inc • Villa Rica, GA, US
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Job Description

Job Description

Summary : The primary responsibility of this role consists of reviewing member transportation requests that are over the contractual mileage guidelines.

ESSENTIAL FUNCTIONS

  • 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.
  • Review for approval / denial determinations for facilities wishing to participate in the organization’s Subscription / Standing Order Transportation Program.
  • Process 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.
  • Run Monthly Denial Summary Report for covered regions and send to the client.

Required Skills and Abilities

  • 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.

    • Minimum Required Education / Training

  • High School graduate or equivalent.
  • 2 years of customer service experience and or employment in the healthcare industry.
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    Utilization Review Specialist • Villa Rica, GA, US