Healthcare Utilization Analyst (Hybrid/Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

Under the direction of the Utilization team manager to provide administrative, operational, and organizational support for the Utilization Management teams.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Researches, assesses, and processes all requests for authorization that are initiated through the call center as well as the "Student Away" phone line and e-mail.
• Authorizations or interactions are completed and documented in the HAP care management software per regulatory guidelines.
• Provides administrative support to management staff related to automated authorization processes, data integrity and error resolution, issues related to the interface of HNM data with HAP systems that affect payment of the claim, network assignment discrepancies, reversing payment denials and tracking of referral benefits.
• Provides direct and day to day resolution for issues relayed through external departments and delegates that include but are not limited Evicore (CareCore National) exception reports, which relate to the authorization and processing of outpatient referral activity.
• When indicated, contact primary care physicians and specialist providers to obtain additional information required for accurate processing of request.
• Develops authorization request review and present to the designated HAP Medical Director for approval or denial.
• Based on decisions made by designated HAP Medical Director, ensures implementation and communication of decision.
• Researches and (through working with the applicable clinical personnel) resolves benefit authorization issues which cannot be decided through application of Health Alliance Plan criteria.
• Prepares denial and approval letters in addition to other written correspondence and reports and maintains files and documents that have mandatory regulatory requirements directly impacting the company's accreditation by NCQA and compliance with CMS and privacy policies.
• Provides Utilization Management staff support and liaison support to committees, including research and proposing appropriate guidelines/criteria.
• Actively participates in assessment and development of proposals to improve utilization patterns, reduce medical costs, enhance provider delivery system, and streamline operational aspects associated with the referral process.
• Responds to incoming calls, faxes, and mail. Facilitates resolution or triage appropriately to ensure timely follow-up to each request. Enters request received via fax into the care management system.
• Performs other related duties as assigned.

HAP Pay Grade: 22 (exempt)