Associate Representative, Clinical
Bright HealthCare, United States

• Provides data entry, filing, tracking time frames and status of case files and providing written and verbal notification of determination to members and providers
• Prepares necessary documentation for utilization management and appeals processes, performs data management and coordinates communication between members of the UM and Appeals teams to ensure timely follow through
• Assist in setting up communications with payors and/ or physicians as applicable, including the use of fax and phone calls
• Reviews providers' requests for services and coordinates utilization/appeals management review
• Notifies Department Leadership of potential missed timeframes for submission and follow-up on responses and escalates cases as appropriate
• Serves as a liaison between patient account services, physicians, care coordinators, Utilization and Appeals Managers, physician advisors and facility departments

• High School Diploma required; Associate or Bachelors’ Degree preferred
• Medical Assistant experience preferred
• Three (3) or more years of healthcare industry experience preferred
• Working knowledge and understanding of basic utilization management concepts preferred
• Prior working experience at a health plan preferred

• Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities
• Excellent written and verbal communication skills
• Able to keep an open line of communication with manager and awareness of situations that need to be escalated
• Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment
• Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools

Job Rewards and Benefits