Description

You will answer first-level calls in Utilization Review for our Health Wellness participants, evaluating certification requests and triaging calls to determine if a Utilization Review Nurse is needed. Your work ensures patients receive appropriate, cost-effective care in accordance with clinical guidelines and insurance requirements.

Requirements

• Experience in a medical setting (receptionist, scheduler, insurance verification, LPN, CNA, Medical Assistant, or customer service background)
• 1+ years of experience in the field
• CNA, LPN, or Medical Assistant preferred
• Strong interpersonal and communication skills
• Detail-oriented with accuracy in reviewing pre-certifications

Responsibilities

• Answer first-level calls in Utilization Review
• Evaluate certification requests by reviewing group-specific requirements
• Triage calls to determine if a Utilization Review Nurse is needed
• Review medical records and coordinate with healthcare providers
• Ensure patients receive appropriate, cost-effective care