Utilization Review Specialist

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    "requisitionDescription": "<div><div><div><div><div><div><p><strong>Summary:&nbsp;</strong> The primary responsibility of this role consists of reviewing member transportation requests that are over the contractual mileage guidelines.</p><p><strong>ESSENTIAL FUNCTIONS</strong></p><ul><li>Reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and or locations.</li><li>Review for approval/denial determinations for facilities wishing to participate in the organization&rsquo;s Subscription/Standing Order Transportation Program.&nbsp;</li><li>Process subscription/Standing order transportation requests from approved facilities for NEMT.</li><li>Investigates transportation provider complaints lodged against Medicaid members during transportation and issuance of Member Warning Letters as warranted.</li><li>Responsible for completing the three departmental reports: daily denial letters, member no-show letters, and monthly denial summary.</li><li>Run Monthly Denial Summary Report for covered regions and send to the client.&nbsp;</li></ul><p><strong>Required Skills and Abilities</strong></p><ul><li>Knowledge of Medicare and Medicaid, community resources, dialysis, and the nursing home placement process.</li><li>Must possess entry to mid-level proficiency in Microsoft Word and Excel.</li><li>Excellent written and verbal communication skills.</li><li>Possesses and demonstrates multi-tasking skills in a high-stress environment while working with multiple internal departments, as well as external entities.</li><li>Analytical thinker with good judgment.</li><li>Well-organized, self-directed individual, who is flexible and takes direction well.</li><li>Possesses a high level of interpersonal skills to handle sensitive and confidential situations.</li></ul><p><strong>Minimum Required Education/Training</strong></p><ul><li>High School graduate or equivalent.&nbsp;</li><li>2 years of customer service experience and or employment in the healthcare industry.</li></ul><p><span style=\"font-size: 14px;\"><br></span></p><p><br></p><p><br></p></div></div></div></div></div></div>\n",
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