Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Associate Utilization Review Assistant is responsible for providing non-clinical support to the Utilization Management (UM) Team. This role supports the operation of the UM team through internal and external customer service. eligibility verification, data entry of authorizations/organization determinations (OD), ensuring completeness of information on authorization/OD requests, assisting providers and members, and processing requests per standard work in order to ensure that Utilization Management activities are completed in a timely and accurate manner in compliance with contractual standards set forth by CMS, Tricare, and NCQA.
Job Description
Key Outcomes:
- Available on a phone queue between 8am and 430pm as needed to support the UM nurses as well as to receive authorization requests and answer general authorization questions from members and providers.
- Manages multiple authorization queues by reviewing, screening, entering, and processing authorization requests from members and providers per HMD guidelines/workflows and contractual/regulatory standards. Uploads faxes to the medical management system.
- Produces notifications by letter to members and providers as required by regulation and accreditation standards.
- Manages the notification queue and sends out daily census information to targeted facilities as needed.
- Participates in and contributes to Health Management Department meetings and process improvement initiatives.
- Complies with all contractual requirements and organizational/departmental standards regarding authorizations, clinical reviews, and provider/member communications.
- Other duties as needed, may be cross trained as back-up for other non-clinical areas of HMD as needed
Education/Experience:
- Associates Degree or equivalent education and experience
- 2 years of managed care experience including experience in a call center
- Experience with CPT, ICD-10 and HCPCS coding a plus
Required License(s) and/or Certification(s):
- Medical Assistant Certification a plus
Skills/Knowledge/Competencies (Behaviors):
- Demonstrates an understanding of and alignment with Martin’s Point Values
- Basic knowledge of medical terminology, current healthcare benefits and managed care insurance plans
- Basic knowledge of Microsoft Word and Excel
- Knowledge of CMS and NCQA regulations a plus
- Demonstrated technical skills in use of office systems, electronic heath records, and databases
- Strong organizational skills (ability to prioritize and multi-task in a high-pressure environment while maintaining focus on organizational objectives)
- Ability to take direction from multiple individuals and prioritize tasks appropriately to meet priorities and deadlines
- Ability to handle confidential and sensitive information in a discreet and professional manner
- Communicates effectively with both internal and external customers
- Ability to function independently
- Critical thinking: Can identify root causes and suggest creative solutions
- Takes appropriate initiative while soliciting input/advice appropriately
- Ability to collaborate with all internal departments and staff with dedication to customer satisfaction
There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]
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What We Do
Martin’s Point Health Care is an innovative not-for-profit health care organization offering high-quality, affordable health care and coverage to the people of Maine and throughout New England.
Martin’s Point has seven health care centers in Maine and New Hampshire offering primary and specialty care to those with most major health insurance plans. Martin’s Point also administers two health insurance plans: Generations Advantage—with the only 5-Star Medicare Advantage plans in northern New England, and the US Family Health Plan for active duty military families and retirees throughout most of northern New England and New York.
We believe that understanding both the clinical and health plan administrative side gives us the insight we need to make meaningful improvements to the health care system. Martin’s Point is dedicated to creating a community of healthy people through authentic relationships and trust
