Utilization Management Representative - DME

 The Utilization Management Representative is responsible for coordinating cases for prior authorization reviews, ensuring compliance with organizational and regulatory requirements. Need to communicate clearly and professionally with members, providers, and internal departments.  This full-time position requires excellent customer service skills, strong attention to detail, and the ability to analyze situations effectively to ensure timely and accurate case processing. The role involves verifying insurance for DME supplies,  submitting prior authorizations, requesting documentation, following up on documentation requests,  processing orders for shipment and maintaining positive customer relations while adhering to company policies and procedures.
  

Responsibilities
• Incoming/Outgoing calls
• Review contract and benefit eligibility.
• Refer cases requiring clinical review to internal review and/or submit to insurance provider for prior authorization

•Data entry
• Respond to telephone and written inquiries from members, providers, Manufacturers, and in-house departments.,
• Conduct clinical screening processes.,
• Request clinical documents from Providers, Follow up on requested documentation

• Develop and maintain positive customer relations and coordinate with various functions within the company.,
• Participate in developing department goals, objectives, and systems.,
• Attend staff meetings and other meetings and seminars as assigned.,
• Recommend new approaches, policies, and procedures to improve department efficiency.,
• Perform other related duties as assigned.

 

 • Minimum of 2 year’s DME experience and/or 2 years Utilization Management experience required (any combination)
• Proven high-quality customer service skills for internal and external customers.
•  Excellent organizational skills and attention to detail.
• Ability to prioritize tasks and communicate effectively to groups.
• Proficient with Microsoft Office Suite – satisfactory completion of our skills testing is required.
•  High school diploma or GED required.