Inpatient Utilization Management Specialist

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Responsible for screening inpatient admissions requests in the utilization management program. Adheres to policies and procedures in order to meet performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. Authorizes certain specified services, under the supervision of the Supervisor, according to departmental guidelines. Per standard workflows, forwards specified requests to the clinician in a timely manner for review and processing. Answers calls from providers and other departments and redirects, as needed.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Prioritizes and processes incoming requests, including authorizing specified inpatient admissions requests, as outlined in departmental policies, procedures, and workflow guidelines
• Requests clinical information and discharge dates per workflow
• Refers requests that require clinical judgment to Inpatient Utilization Clinician
• Meets or exceeds position metrics and turnaround timeframes while maintaining a full workload
• Supports inpatient admission Clinicians
• Answers provider calls and follows up with the information necessary to complete the caller’s request within assigned timeframe
• Coordinates resolution of escalated provider inquiries
• Informs provider of authorization decision per department procedure
• Works with providers and key departments to promote an understanding of inpatient admissions requirements and processes
• Maintains general understanding of applicable sections of member handbooks, evidence of coverage, and company website
• Processes Utilization Management Department reports as assigned
• Handles and follows up on claims related questions
• Participates in team operational activities, including but not limited to primary responsibilities for triage function and department voicemail coverage
• Other duties as assigned
  

Qualifications

Education Required:

• Associate’s degree in Healthcare, Nursing, Social Work or a related area or equivalent relevant work experience is required
  
  

Experience Required

• 2 years of office experience, specifically in either a high volume data entry office, customer service call center, or health care office administration department
  
  

Preferred/Desirable

• Experience with CCMS, JIVA, FACETS or other healthcare database
• Experience with Health Plan Utilization/Claims Department
• Knowledge of Healthcare, including MassHealth rules and regulations
• Prior customer service experience
• Bilingual skills, fluency in Spanish
  
  

Competencies, Skills And Attributes

• Strong customer service and skills
• Strong listening, written and verbal communication skills
• Ability to prioritize and manage multiple tasks in fast-paced environment within turnaround time
• Ability to accurately process high volumes of requests at department defined accuracy rate
• Strong MS Office skills and ability to learn new technical systems
  
  

Working Conditions And Physical Effort

• Ability to work overtime if required
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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