Senior Utilization Management Specialist

Requisition ID:879910

Store #:110342 EM Provider Ops - OH CSC

Position:Full-Time

Total Rewards:Benefits/Incentive Information

At EyeMed, we have a unique perspective on vision benefits. By listening and staying curious, we create innovative vision benefits that are a joy to use.

Our mission is to help people see life to the fullest-and our commitment goes beyond vision benefits. Our passionate employees proudly support the OneSight EssilorLuxottica Foundation, a leading not-for-profit organization with a 100% focus on eradicating the world's vision crisis.

EyeMed is part of EssilorLuxottica, a global leader in the design, manufacture and distribution of world-class vision care products, including iconic eyewear, advanced lens technology and cutting-edge digital solutions. Join our global community of over 200,000 dedicated employees around the world in driving the transformation of the eyewear and eyecare industry. Discover more by following us on LinkedIn.

GENERAL FUNCTION

The Sr. Specialist- Utilization is a nurse leader responsible for providing administrative support to utilization management operations.

MAJOR DUTIES AND RESPONSIBILITIES

• Oversees daily workflow of Utilization Management clinical and non-clinical staff.
• Responsible for oversight of daily turnaround time compliance.
• Acts as a liaison between Utilization Management and providers, handling complaints and partnering with individual account managers to facilitate the client relationship.
• Gathers clinical information regarding cases and determines appropriate area to refer or assign case (utilization management, QA, appeals).
• Conducts initial medical record review and interpretation, applies critical thinking skills to ensure appropriate utilization and medical necessity of authorization requests received
• Creates all member and provider notifications, adhering to regulatory, compliance and accreditation requirements as outlined in department policy and procedure documents
• Prepares, reports and documents all clinical case information
• Responds to requests, calls or correspondence with the Utilization Management department
• Makes outbound calls to members and providers
• Provides general program information to members and providers
• Acts as liaison between utilization management operations and other internal departments to support ease of administration of medical and vision benefits
• Interact and coordinate with clinical peer reviewers
• Consults with a nurse reviewer, clinical peer reviewer or the Medical Director with questions
• Prepare case files for external reviews or forwarding to health plans
• Maintains record and documents results of the clinical review and determination in the medical management information system
• Maintains confidentiality for patient data and provider specific information
• Maintain awareness of industry trends and developments related to utilization management and the measurement of vision care quality and cost efficiency.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

BASIC QUALIFICATIONS

• Associate's Degree or equivalent work experience
• LPN
• 3 years of experience in health care administration and/or utilization management with knowledge of Medicaid/Medicare concepts
• Experience with medical terminology and medical coding
• Strong written and oral communication skills
• Proficient in Microsoft Office (Access, Excel, PowerPoint, Word)
• Strong organization and multi-tasking skills
• Demonstrated ability to meet deadlines
• High sense of urgency

PREFERRED QUALIFICATIONS

• RN
• Experience in an eye care provider setting
• Experience participating in external audits
• Experience in Project Management
• Ability to manage time and tasks independently

Employee pay is determined by multiple factors, including geography, experience, qualifications, skills and local minimum wage requirements. In addition, you may also be offered a competitive bonus and/or commission plan, which complements a first-class total rewards package. Benefits may include health care, retirement savings, paid time off/vacation, and various employee discounts.

Upon request and consistent with applicable laws, EssilorLuxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process. To request a reasonable accommodation, please call the EssilorLuxottica SpeakUp Hotline at 844-303-0229 (be sure to provide your name and contact information so that we may follow up in a timely manner) or email HRCompliance@luxotticaretail.com.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law. Native Americans in the US receive preference in accordance with Tribal Law.