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Utilization Management Customer Service Rep at ConcertoHealth
Aliso Viejo, CA, US

Job Details

Description

 

ABOUT CONCERTO HEALTH

ConcertoHealth Inc. is the leading provider of specialized primary care and supporting clinical services for complex, frail, elderly, and dual-eligible patients. Operating exclusively in value-based agreements, ConcertoHealth provides high-touch, individualized care for patients, and deploys wraparound clinical resources to extend the reach of primary care practices. This comprehensive medical management solution, elevated by Concerto’s proprietary population health technology, improves overall healthcare quality and patient outcomes, benefitting payers and their provider networks.

Concerto delivers comprehensive care to Medicare, Medicaid, and complex-needs patients.  The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. Our approach focuses on bringing harmony across the spectrum of a patient’s care, health, and dignity.

The company is headquartered in Aliso Viejo, Ca. For more information, please visit: www.concertohealth.com

JOB SUMMARY

The UM Customer Service Representative is responsible for successfully managing a high volume of inbound and outbound calls while providing exemplary customer service. Performing this activity will include following communication scripts, addressing many different situations, and acting as a liaison between ConcertoHealth and its Health Plan partners, patients, providers, and vendors.  In addition, the UM Customer Service Representative is responsible for evaluating incoming documents to determine if required information is complete or if outreach is needed. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Manages incoming calls from physicians, ancillary providers, patients, and plan representatives regarding referral authorization requests and requirements.
  • Accurately tracks and enters calls in computer system using appropriate documentation, reporting, and database applications.
  • Reviews incoming phone referral requests for completeness of information provided.
  • Functions as a liaison between ConcertoHealth and members as well as providers regarding authorization requests, physician/vendor information, and complaint resolution.  Aware when to escalate issues to a higher level.
  • Interacts with plan partners and multiple departments, e.g., Utilization Management, Claims, and Eligibility to provide resolution to provider, member, and health plan/vendor inquiries. Supports positive internal relations and communication across all areas.
  • Understands and uses proper procedures to resolve problems, escalate issues, and achieve objectives in a productive and cooperative manner. Provides timely feedback about processes to improve caller experiences and satisfaction.
  • Notifies members of urgent approvals and denials within appropriate time frames, using appropriate guidelines.
  • Supports overall department operations through cooperation and teamwork.

QUALIFICATIONS

  • High School Diploma.
  • Knowledge of Medical Terminology.
  • Ability to navigate multiple PC applications simultaneously. Knowledge and experience using Microsoft ® Office required.
  • Minimum of two (2) years of outbound/inbound calling experience in a call center, medical office/clinic or institutional setting.
  • Ability to convey a positive and professional image to customers and employees.
  • Display patience and demonstrates respect for callers and staff. Maintains composure in high pressure situations.
  • Willing and able to follow an issue through to its conclusion.
  • Excellent written/verbal communication skills.
  • Ability to work in a fast-paced environment and maintain a high level of productivity.
  • Ability to prioritize and handle multiple tasks effectively and efficiently, remain flexible, and adapt to shifting work demands.
  • Strong organizational and time management skills. Able to work independently, but also as a team player.
  • Customer service experience in a managed care environment highly desirable.

COMPETENCIES

We are an Equal Opportunity Employer

CONCERTOHEALTH IS AN ALCOHOL/DRUG/SMOKE-FREE WORKPLACE

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is required to stand; walk and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.